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Questions 164

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Question 1 of 5

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate?

Correct Answer: C,D,E

Rationale: Inspecting for skin breakdown (
C), measuring postvoid residuals (
D), and double voiding (E) manage overflow incontinence. Restricting fluids (
A) risks dehydration, and bearing down (
B) may worsen incontinence.

Question 2 of 5

The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, 'I already have a power of attorney.' What is the best response by the nurse?

Correct Answer: D

Rationale: Clarifying if the POA includes healthcare decisions (
D) ensures proper advance directive planning. Vague affirmations (A,
B) or suggesting a lawyer (
C) do not address the need for a healthcare-specific POA.

Question 3 of 5

Which of the following clients is at highest risk for developing Sarcordosis?

Correct Answer: B

Rationale: Sarcoidosis is most common in African-Americans, particularly women of childbearing age, making the pregnant 30-year-old African-American the highest risk.

Question 4 of 5

A 78-year-old client is admitted following a cerebrovascular accident. He cannot move his left arm and leg. Which finding would indicate to the nurse that the client also has homonymous hemianopia?

Correct Answer: B

Rationale: Homonymous hemianopia, a visual field defect from right brain stroke, causes left-sided vision loss, so the client misses the nurse on the left, unlike arm movement, swallowing, or speech issues.

Question 5 of 5

The nurse in a college health clinic is teaching the male students testicular self-examination. Which statement made by one of the young men indicates a need for more teaching?

Correct Answer: D

Rationale: Testicular cancer primarily affects younger men (15–35 years), not older men, indicating a need for more teaching. Monthly exams, shower timing, and reporting lumps are correct.

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