Nokea
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. B/c doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B. The client's statement indicates an understanding of the recommended screening guideline for mammograms for a 45-year-old individual with no specific family history of cancer. Yearly mammograms are typically recommended starting at age 40 for early detection of breast cancer. Choice A is incorrect as colon cancer screening is recommended starting at age 45-50, not in 2-3 years. Choice C is incorrect as Pap smears are typically recommended every 3-5 years, not yearly. Choice D is incorrect as blood glucose testing is usually recommended annually for individuals at risk for diabetes.
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Nurse in clinic caring for 21-year-old client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client?
- A. Testicular exam
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct Answer: A
Rationale: The correct answer is A: Testicular exam. The provider should perform this screening for a 21-year-old male as part of routine health maintenance. Testicular cancer is most common in young males, and early detection through a testicular exam is crucial for successful treatment. Blood glucose (B) screening is typically done for diabetes risk assessment, which is less likely in a young, asymptomatic individual. Fecal occult blood (C) screening is for colorectal cancer, typically recommended for individuals over 50. Prostate-specific antigen (D) screening is for prostate cancer, which is rare in young males and not recommended without specific risk factors.
As part of admission process
- A. nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family?
- B. BMI
- C. Usual times for meals/snacks
- D. Favorite foods
- E. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Favorite foods. This is because knowing the client's favorite foods is crucial in ensuring they receive proper nutrition and enjoy their meals, especially for someone with dementia who may have difficulty remembering or expressing preferences. It helps enhance their quality of life and promotes adequate food intake.
Other choices are less critical:
A: Nutrition history can include various components, not just family input.
B: BMI is important but not the priority when gathering nutrition information.
C: Knowing meal/snack times is relevant but not as crucial as favorite foods.
E: Swallowing difficulty is important but not the priority in this scenario.
A nurse is assessing body alignment. What is the nurse monitoring?
- A. The relationship of one body part to another while in different positions
- B. The coordinated efforts of the musculoskeletal and nervous systems
- C. The force that occurs in a direction to oppose movement
- D. The inability to move about freely
Correct Answer: A
Rationale: The correct answer is A. The nurse is monitoring the relationship of one body part to another while in different positions to ensure proper alignment. This is crucial for preventing musculoskeletal issues. Choice B refers to coordination, not body alignment. Choice C refers to resistance, not alignment. Choice D refers to immobility, not alignment.
A home health nurse is discussing dangers of carbon monoxide poisoning with a client. What information should the nurse include?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with hemoglobin in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is correct because carbon monoxide binds with hemoglobin in the blood more easily than oxygen, leading to decreased oxygen delivery to tissues. This can result in symptoms of carbon monoxide poisoning.
A: Carbon monoxide is odorless, so this is incorrect.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body by interfering with oxygen transport, not by directly damaging the lungs.
In summary, choice D is correct because it explains the mechanism of carbon monoxide poisoning, while the other choices are incorrect as they do not directly relate to the dangers of carbon monoxide poisoning.
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer from PACU following thoracic surgery. To which staff member should the nurse assign this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from PACU after thoracic surgery. RNs have the education and training to assess the client's condition, monitor vital signs, manage postoperative pain, and recognize any complications that may arise. They can also provide the necessary interventions and communicate effectively with the healthcare team. Assigning this client to an RN ensures safe and competent care.
Choice A (Charge nurse) may have administrative duties and may not be available to provide direct care. Choice C (LPN) may not have the scope of practice or training to manage postoperative care for a client following thoracic surgery. Choice D (AP) does not have the qualifications to assess and manage a client with complex postoperative needs.