The nurse is collecting data to determine the client’s risk factors related to cervical cancer. The nurse determines which information to be significant?
Multiple sexual partners.
Multiple pregnancies.
Late onset of menarche.
Use of a diaphragm.
The Correct Answer is A
Choice A rationale
Multiple sexual partners increase the risk of human papillomavirus (HPV) infection, which is a significant risk factor for cervical cancer.
Choice B rationale
Multiple pregnancies are not a significant risk factor for cervical cancer.
Choice C rationale
Late onset of menarche is not a significant risk factor for cervical cancer.
Choice D rationale
Use of a diaphragm is not a significant risk factor for cervical cancer.
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Correct Answer is D
Explanation
Choice A rationale
Asking the client if she would prefer a liquid diet does not promote independence in eating. It may limit the client’s dietary options and does not address the need for the client to learn how to eat independently with bilateral eye patches.
Choice B rationale
Assigning an assistive personnel to feed the client does not promote independence. It makes the client reliant on others for feeding, which does not help in developing self-feeding skills.
Choice C rationale
Explaining to the client that her tray is here and placing her hands on it is a step towards promoting independence. However, it does not provide enough information for the client to locate and identify the food items on the tray independently.
Choice D rationale
Describing to the client the location of the food on the tray promotes independence by enabling the client to use her sense of touch and memory to locate and consume the food items without assistance.
Correct Answer is C
Explanation
Choice A rationale
Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.
Choice B rationale
Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.
Choice C rationale
Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.
Choice D rationale
Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.