During the history, which information from a 21-year-old client would indicate a risk for development of testicular cancer?
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Solution
Undescended testicle
Undescended testicles make the client high risk for testicular cancer. Mumps, inguinal hernia in childhood, orchitis, and testicular cancer in the contralateral testis are other predisposing factors.
Which action by the mother of a preschooler would indicate a disturbed family interaction?
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Solution
Tells her child that if he does not sit down and shut up she will leave him there.
Threatening a child with abandonment will destroy the child’s trust in his family.
While performing a physical examination on a newborn, which assessment should be reported to the physician?
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Solution
Head circumference of 40 cm
Average circumference of the head for a neonate ranges between 32 to 36 cm. An increase in size may indicate hydrocephalus or increased intracranial pressure.
Which nursing intervention would be a priority during the care of a 2-month-old after surgery?
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Solution
Encourage stroking of the infant
Tactile stimulation is imperative for an infant’s normal emotional development. After the trauma of surgery, sensory deprivation can cause failure to thrive.
Which nursing approach would be most appropriate to use while administering an oral medication to a 4 month old?
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Solution
Place medication in an empty nipple
This is a convenient method for administering medications to an infant. Option D is partially correct however, the infant is never placed in a reclining position during a procedure due to a potential aspiration.
The nurse assesses a prolonged late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing intervention would be to:
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Solution
Turn off the infusion
Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus, which is a possible cause of the deceleration.
What question would be most important to ask a male client who is in for a digital rectal examination?
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Solution
“Have you noticed a change in the force of the urinary system?”
This change would be most indicative of a potential complication with (BPH) benign prostate hypertrophy.
An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?
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Solution
Feed the infant glucose water (10%)
After birth, the infant of a diabetic mother is often hypoglycemic.
Which technique would be best in caring for a client following receiving a diagnosis of a state IV tumor in the brain?
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Solution
Providing accurate information about the disease and treatment options
Providing information for the client is the best technique for a new diagnosi
What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?
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Solution
A tongue depressor and flashlight
Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated.