A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks the nurse to explain what a hernia is. How should the nurse respond?

Tell him not to worry and that most men his age develop hernias

Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles

Explain that a hernia is often the result of prenatal growth abnormalities

Refer him to his physician for additional consultation because the physician made the initial diagnosis

Answer and Explanation

The Correct Answer is B

Choice A reason: Telling the patient not to worry dismisses their concern and provides no educational value. Inguinal hernias, while common in older men, require explanation and monitoring, as they can lead to complications like incarceration, making this an inappropriate response.

Choice B reason: An inguinal hernia is a protrusion of bowel or tissue through a weak spot in the abdominal wall, typically in the inguinal canal. This accurate explanation addresses the patient’s question, describing the condition’s pathophysiology clearly, making it the correct response.

Choice C reason: Inguinal hernias are typically acquired due to abdominal wall weakness or increased intra-abdominal pressure, not prenatal growth abnormalities. Congenital hernias (e.g., indirect inguinal) are less common in adults, making this an inaccurate explanation for the patient’s condition.

Choice D reason: Referring the patient back to the physician avoids the nurse’s responsibility to educate. Nurses are equipped to explain diagnoses like hernias in simple terms, and deferring entirely does not address the patient’s immediate need for understanding, making this less optimal.

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Correct Answer is A

Explanation

Choice A reason: To calculate the dose, divide the ordered 180 mg by the concentration of 250 mg per 5 ml: (180 mg ÷ 250 mg) × 5 ml = 0.72 × 5 = 3.6 ml. This precise calculation ensures the correct amount of Dilantin is administered, matching the provider’s order.

Choice B reason: A 4.5 ml dose would deliver 225 mg (4.5 ml × 250 mg/5 ml), exceeding the ordered 180 mg. This overdose could increase the risk of toxicity, as Dilantin has a narrow therapeutic range, making this an incorrect choice.

Choice C reason: A 5 ml dose delivers 250 mg (5 ml × 250 mg/5 ml), significantly more than the ordered 180 mg. This excessive dose could lead to adverse effects like ataxia or nystagmus, rendering this choice incorrect for the prescribed amount.

Choice D reason: A 7 ml dose would provide 350 mg (7 ml × 250 mg/5 ml), far exceeding the ordered 180 mg. Such a high dose could cause severe toxicity, including neurological symptoms, making this an inappropriate and unsafe choice.

A. The eyes converge and the pupils constrict to focus on the light. B. The constriction of both pupils occurs in response to bright light. C. The eyes focus the image in the center of the macula for precise vision. D. The eyes are normally aligned when the light is in the same location on each eye.

Correct Answer is D

Explanation

Choice A reason: Convergence and pupil constriction are accommodation reflexes, not corneal light reflex, which tests alignment. Light reflection symmetry indicates eye alignment, so this incorrect for the reflex’s purpose.

Choice B reason: Pupil constriction is a pupillary reflex, not corneal light reflex. The corneal reflex involves light reflection on corneas, assessing alignment, not pupil response, so this is incorrect.

Choice C reason: Macular focus is related to visual acuity, not corneal reflex, light reflex, which checks eye alignment via light reflection. Symmetric reflection is key, so this incorrect for the reflex’s indication.

Choice D reason: A normal corneal reflex shows light reflecting in the same spot on both corneas, indicating proper eye alignment. This is the definition of the reflex, making it the correct choice for eye assessment.

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A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks the nurse to explain what a hernia is. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The provider has ordered 180 mg of Dilantin PO every 8 hours. The label of the drug reads 250 mg per 5 ml. How many milliliters will the nurse administer per dose?

Correct Answer is A

Explanation

A patient has a normal corneal light reflex. The nurse recognizes that this reflex indicates which information about the eyes?

Correct Answer is D

Explanation

Which is the most important step that the nurse can take to prevent the transmission of microorganisms in the hospital?

When the nurse asks an older patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding?

When examining the face, the nurse is aware that which two pairs of salivary glands are accessible for palpation?

A patient arrives at the emergency center with a severe head injury. During assessment, the nurse observes that the patient is unresponsive, adducts the arms tightly against the thorax, and plantar flexes the feet while internally rotating them. How would the nurse document this abnormal posture?

A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks the nurse to explain what a hernia is. How should the nurse respond?

A nurse is teaching a group of teen women. Which should the nurse discuss as the risk factor most associated with cervical cancer?

A nurse is teaching a patient to perform self-breast examination and tells the patient to pay particular attention to examining the upper outer quadrant of the breast. When asked why, “why,” how should the nurse respond to the patient?

A nurse suspects abuse when a 6-year-old child is taken to the emergency center for a traumatic injury. How should the nurse document the assessment findings?