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How should the nurse record the observation of a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands?
- A. Hand assistance
- B. Leg crawling
- C. Gowers sign
- D. Bright sign
Correct Answer: C
Rationale: The correct term for a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands is known as the Gowers sign. This maneuver is characteristic of Duchenne muscular dystrophy due to proximal muscle weakness. Choices A, B, and D are incorrect because they do not specifically describe the action of walking up the thighs with the hands, which is a distinctive feature of the Gowers sign.
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A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained and leaves the present IV in place. What is the greatest clinical risk related to this situation?
- A. Impaired skin integrity
- B. Fluid volume excess
- C. Acute pain and anxiety
- D. Peripheral neurovascular dysfunction
Correct Answer: A
Rationale: The correct answer is A: Impaired skin integrity. In this situation, the greatest clinical risk is related to impaired skin integrity due to the potential extravasation of the vesicant. Vesicants are substances that can cause severe tissue damage if they leak into the surrounding tissues. Choices B, C, and D are not the most significant risks in this scenario. Fluid volume excess, acute pain, and peripheral neurovascular dysfunction are not directly associated with leaving the IV in place with a known vesicant for an extended period.
Which individual has the highest risk for developing skin cancer?
- A. A 16-year-old dark-skinned female who tans in tanning beds once a week.
- B. A 65-year-old fair-skinned male who is a construction worker
- C. A 25-year-old dark-skinned male whose mother had skin cancer.
- D. A 70-year-old fair-skinned female who works as a secretary.
Correct Answer: B
Rationale: The correct answer is B, a 65-year-old fair-skinned male who is a construction worker. Fair-skinned individuals are at higher risk of developing skin cancer due to prolonged sun exposure. Construction workers are often exposed to the sun for long periods, further increasing the risk. Choices A, C, and D are less likely to develop skin cancer compared to choice B due to factors such as age, frequency of tanning bed use, and occupation.
The nurse provides dietary instructions about iron-rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
- A. Liver.
- B. Oranges.
- C. Leafy green vegetables.
- D. Kidney beans.
Correct Answer: B
Rationale: The correct answer is B: Oranges. Oranges are not a rich source of iron. Iron-rich foods include liver, leafy green vegetables, and kidney beans. Oranges are a good source of vitamin C but are not high in iron. Therefore, if the client selects oranges as an iron-rich food, it indicates a need for additional instructions on choosing foods high in iron.
An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?
- A. Assist with personal care, but leave oral care for the nurse to complete.
- B. Provide a soft bristle brush for the client to use during oral care.
- C. Use alcohol-based mouthwash to clean the ulcers.
- D. Apply an antifungal cream to the mouth ulcers.
Correct Answer: B
Rationale: The correct answer is B: 'Provide a soft bristle brush for the client to use during oral care.' Providing a soft bristle brush helps reduce trauma to the oral mucosa and assists in oral care. Choice A is incorrect because oral care can be safely delegated to UAPs. Choice C is wrong as alcohol-based mouthwash can further irritate the ulcers. Choice D is incorrect as applying an antifungal cream directly to the mouth ulcers is not the standard treatment for oral candidiasis.
What is the most effective therapy for maintaining remission of acute lymphoblastic leukemia in a child?
- A. Surgery to remove enlarged lymph nodes
- B. Long-term chemotherapy
- C. Nutritional supplements to enhance blood cell production
- D. Blood transfusions to replace ineffective red cells
Correct Answer: B
Rationale: The correct answer is B: Long-term chemotherapy. In the case of acute lymphoblastic leukemia, the most effective approach for maintaining remission is long-term chemotherapy, particularly with methotrexate, a chemotherapeutic agent. Surgery to remove enlarged lymph nodes (choice A) is not the primary treatment for leukemia. Nutritional supplements (choice C) may be beneficial for overall health but are not the mainstay of leukemia treatment. Blood transfusions (choice D) are used to manage anemia in leukemia but do not address the underlying disease process.