Nokea
A client asks the nurse what risk factors increase the chances of getting skin cancer. The risk factors include all except:
- A. light or fair complexion.
- B. exposure to sun for extended periods of time.
- C. certain diet and foods.
- D. history of bad sunburns.
Correct Answer: C
Rationale: The correct answer is 'certain diet and foods.' Risk factors that increase the chances of getting skin cancer include having a light or fair complexion, a history of bad sunburns, personal or family history of skin cancer, outdoor activities with sun exposure, exposure to X-rays or radiation, exposure to certain chemicals, repeated trauma or injury resulting in scars, age over 50, male gender, and living in specific geographic locations. These factors can contribute to the development of skin cancer. Avoiding exposure to the sun, using protective clothing and sunscreen, and regular skin inspections are key preventive measures. Choice C, 'certain diet and foods,' is incorrect as diet is not a primary risk factor for skin cancer. Options A, B, and D are all valid risk factors associated with an increased risk of developing skin cancer.
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A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?
- A. Coffee
- B. A tuning fork
- C. A wisp of cotton
- D. An ophthalmoscope
Correct Answer: C
Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I. Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve). Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.
The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?
- A. Health promotion
- B. Secondary prevention
- C. Tertiary prevention
- D. Primary prevention
Correct Answer: B
Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke.
Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia.
Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them.
Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.
The LPN participates in a home visit for a client with Type 2 Diabetes who has been taking Metformin for 3 years. The client states that for the past 3 months, they have been trying a vegan diet and experiencing fatigue, confusion, and mood changes. What is a likely cause of the new symptoms?
- A. vitamin B12 deficiency
- B. chronic hypoglycemia
- C. vitamin D deficiency
- D. increased tolerance to Metformin
Correct Answer: A
Rationale: The correct answer is vitamin B12 deficiency. Long-term use of Metformin can lead to vitamin B12 deficiency, and a vegan diet is low in vitamin B12. Symptoms of vitamin B12 deficiency include anemia, fatigue, confusion, and mood changes. Chronic hypoglycemia is unlikely in a client with Type 2 Diabetes who has been taking Metformin as it typically causes hyperglycemia. Vitamin D deficiency usually presents with symptoms related to bones and muscles, not confusion and mood changes. Increased tolerance to Metformin does not explain the client's new symptoms, which are more indicative of a nutritional deficiency like vitamin B12.
What is the primary nutritional deficiency of concern for a strict vegetarian?
- A. vitamin C
- B. vitamin B12
- C. vitamin E
- D. magnesium
Correct Answer: B
Rationale: Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian. While all mentioned vitamins are essential for overall health, vitamin B12 is particularly important for vegetarians as it is mainly found in animal products. A strict vegetarian diet may lack sufficient vitamin B12 intake, leading to potential health issues like anemia and neurological problems. Vitamin C deficiency is more commonly associated with scurvy, which is preventable with a diet rich in fruits and vegetables. Vitamin E deficiency is rare and usually only seen in specific medical conditions. Magnesium deficiency is not typically a primary concern for strict vegetarians as magnesium can be obtained from a variety of plant-based sources.
Which of the following is not a nursing responsibility when preparing the client for central line insertion?
- A. advancing the guidewire
- B. explaining the procedure to the client
- C. maintaining sterile technique
- D. ensuring necessary consents are signed
Correct Answer: A
Rationale: When preparing a client for central line insertion, nursing responsibilities include explaining the procedure to the client, ensuring necessary consents are signed according to the facility policy, and maintaining sterile technique when preparing the equipment and supplies. Advancing the guidewire is typically performed by the practitioner inserting the central line, not the nurse. It requires specialized training and expertise beyond the scope of nursing practice. Therefore, the correct answer is advancing the guidewire. Option A is the correct answer because it delineates an activity that is not within the usual scope of nursing practice during central line insertion preparation. Options B, C, and D are incorrect as they reflect essential nursing responsibilities in this context.