The nurse has taught a 23-year-old patient how to perform a testicular self-examination. Which statement by the patient indicates the need for further teaching?
a. "The testes feel smooth and egg-shaped."
b. "The best time to perform TSE is after a shower."
c. "The best time to perform TSE is just before intercourse."
d. "The epididymis feels like a soft tube."
C
Perform TSE after a bath or shower when scrotum is warm and most relaxed. The testes should feel smooth and be firm to touch.
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The nurse understands that when the spinal cord is injured, ischemia and edema result. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week?
1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury two cord segments above and below the affected level." 3. "Neurons need time to regenerate, so stating the extent of injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury."
After several doses of chemotherapy, a patient complains of fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia. Which NANDA nursing diagnosis would the nurse list as the first priority?
1. Imbalanced Nutrition: Less than Body Requirements 2. Activity Intolerance 3. Powerlessness 4. Ineffective Coping
The nurse is caring for the patient after general anesthesia. How often does the nurse perform routine patient assessment and documentation in the postanesthesia care unit (PACU)?
a. Every 5 minutes b. Every 5 to 15 minutes c. Every 15 to 30 minutes d. Every 30 minutes to 1 hour
When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?
A. Hiding liquor bottles in a closet B. Yelling at their son for slouching in his chair C. Burning dinner on purpose D. Saying to the spouse, "I don't drink too much!"