A nurse is reinforcing teaching with a group of adolescent male clients about testicular examinations. Which of the following statements by a client indicates an understanding of the teaching?

"I should perform a self-examination of my testicles weekly."

"I should bear down when cupping my testes while I'm checking for abnormalities."

"I should apply gentle pressure with my thumb and forefinger when examining my testes."

"I should expect one testicle to be larger than the other."

Answer and Explanation

The Correct Answer is C

A. "I should perform a self-examination of my testicles weekly" is not recommended. Testicular self-exams should be done monthly, not weekly, as this frequency is enough to notice any changes or abnormalities.

B. "I should bear down when cupping my testes while I'm checking for abnormalities" is incorrect. There is no need to bear down during the self-examination. The testicles should be examined gently and without exerting pressure, as bearing down can make the examination uncomfortable.

C. "I should apply gentle pressure with my thumb and forefinger when examining my testes" is the correct statement. The testicular self-exam should be done gently, with light pressure to feel for any lumps or abnormalities.

D. "I should expect one testicle to be larger than the other" is a common misconception. It is normal for one testicle to be slightly larger than the other, but this should be checked regularly to ensure there are no significant changes or signs of concern.

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Correct Answer is B

Explanation

A. The client's potassium level is 2.7 mEq/L is incorrect. A potassium level of 2.7 mEq/L is low and indicates hypokalemia, which is a life-threatening condition that can occur in anorexia nervosa, particularly if the client is engaging in behaviors like purging. This level should be addressed immediately, not considered a positive outcome.

B. The client resumes menstruation is correct. The resumption of menstruation is a positive outcome of treatment for anorexia nervosa. It indicates that the client's nutritional status has improved and that the body is starting to regain normal function after addressing issues like malnutrition and hormonal imbalances.

C. The client's pulse rate is 44/min is incorrect. A pulse rate of 44/min is bradycardia, which is a common sign of anorexia nervosa due to malnutrition and the body's attempt to conserve energy. While it may improve with treatment, this finding would not be considered a positive outcome.

D. The client develops lanugo is incorrect. Lanugo (fine, soft hair) typically develops in severe anorexia nervosa due to malnutrition and is a sign of starvation. The appearance of lanugo is not a positive outcome but rather a compensatory mechanism to retain heat, indicating that the client is still in a malnourished state.

A. "This must be very frightening for you. Let's talk more about it." B. "What makes you think the staff is following you?" C. “Why do you feel the staff is the FBI?" D. "The psychiatric staff is not FBI. They are here to help you."

Correct Answer is A

Explanation

A. "This must be very frightening for you. Let's talk more about it.": This response demonstrates empathy and validation of the client's feelings, which can help build trust. It acknowledges the client's emotional state while not challenging or confronting their delusion directly. This approach helps maintain rapport while encouraging the client to express themselves.

B. "What makes you think the staff is following you?": This response could be perceived as questioning the validity of the client's experience, which may feel confrontational or invalidating. It is not the best approach for engaging a client with paranoid delusions.

C. “Why do you feel the staff is the FBI?": This question could also challenge the client's delusion and inadvertently reinforce their sense of being persecuted. Asking such a question might escalate anxiety rather than calm the client.

D. "The psychiatric staff is not FBI. They are here to help you.": While this response is factually correct, it may be perceived as dismissive of the client's experience. Confronting the delusion directly is generally not helpful and can increase the client's feelings of mistrust.

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A nurse is reinforcing teaching with a group of adolescent male clients about testicular examinations. Which of the following statements by a client indicates an understanding of the teaching?

Nursing Test Bank

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