A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?

Correct Answer: D

Rationale: The correct answer is D because a class V finding on a Pap test indicates severe dysplasia or carcinoma in situ, which requires further evaluation through a biopsy to confirm the presence of abnormal cells. This finding is not normal and necessitates immediate action for diagnosis and potential treatment. Choices A, B, and C are incorrect because they do not address the urgency and seriousness of a class V finding, which mandates prompt follow-up to rule out or confirm the presence of precancerous or cancerous cells.

Correct Answer: A

Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.

Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and possibly disrespectful attitude towards the nurse. This can hinder effective communication and collaboration. A: Shows understanding of hallucinations. C: Demonstrates assistance to the father. D: Reflects consideration for the father's needs. B is incorrect as it does not promote positive interaction.

Correct Answer: B

Rationale: The correct answer is B: Positioning the patient on his or her side. This is essential for a lumbar puncture as it helps to open up the spinal spaces, making it easier and safer for the procedure. Positioning the patient on their side also helps prevent complications such as nerve damage or spinal fluid leakage. A: Administering enemas until clear is unnecessary and not directly related to preparing a patient for a lumbar puncture. C: Removing all metal jewelry is important to prevent interference with imaging studies, but it is not directly related to preparing for a lumbar puncture. D: Removing the patient’s dentures is not specifically required for a lumbar puncture procedure.

Correct Answer: B

Rationale: The correct answer is B, Altered level of consciousness, because it is a critical assessment in determining Mr. Reyes's neurological status and overall well-being. Assessing for altered level of consciousness helps identify potential neurological issues, such as brain injury or stroke, which require immediate intervention. A: Decreased carotid pulses - This is related to cardiovascular assessment, not specific to Mr. Reyes's neurological status. C: Bleeding from oral cavity - While important to assess for, it is not directly related to Mr. Reyes's neurological status. D: Absence of deep tendon-reflexes - This is a specific neurological assessment, but altered level of consciousness takes priority in this scenario.

Correct Answer: B

Rationale: Step 1: Guillain-Barre Syndrome (GBS) is characterized by a rapid onset of weakness and tingling sensations in the legs. Step 2: Paresthesia refers to abnormal sensations like tingling or numbness, which is a common initial neurological symptom of GBS. Step 3: Absent tendon reflexes may occur in GBS due to muscle weakness but are not typically the initial symptom. Step 4: Dysrhythmias and transient hypertension are not typical symptoms of GBS and are not associated with its initial presentation. In summary, choice B is correct as paresthesia of the legs is a hallmark initial neurological symptom of Guillain-Barre Syndrome, while choices A, C, and D are incorrect as they do not align with the typical presentation of GBS.

Correct Answer: D

Rationale: The correct answer is D: Calcium. Calcium is necessary for the chemical clotting process because it plays a crucial role in the activation of various clotting factors, leading to the formation of a blood clot. Without sufficient calcium, the clotting cascade would not be able to proceed effectively. Iron (choice A) is essential for red blood cell production, not clotting. Potassium (choice B) and Sodium (choice C) are important for various physiological functions but are not directly involved in the clotting process.

Correct Answer: A

Rationale: The correct answer is A: Muscle weakness. After unilateral adrenalectomy, there is a risk of hyperkalemia due to decreased aldosterone production. Aldosterone helps regulate potassium levels in the body. Muscle weakness is a common symptom of hyperkalemia as high potassium levels can affect muscle function. Diaphoresis, tremors, and constipation are not typically associated with hyperkalemia. Diaphoresis is excessive sweating, tremors are involuntary muscle movements, and constipation is difficulty passing stool. These symptoms are not directly related to potassium imbalance.

Correct Answer: C

Rationale: The correct answer is C: Eating. Chewing food can trigger trigeminal nerve pain due to the movement and pressure applied on the nerve. The other choices (A: Sleeping, B: Reading, D: Cooking) do not involve the same level of jaw movement and pressure on the trigeminal nerve, thus are less likely to aggravate the pain. Therefore, eating is the most likely action to worsen trigeminal neuralgia symptoms in this scenario.