Nokea
A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
- A. Plantar fasciitis.
- B. Hallux valgus.
- C. Hammertoe.
- D. Morton's neuroma.
Correct Answer: D
Rationale: The correct answer is Morton's neuroma. Morton's neuroma is a small mass or tumor in a digital nerve of the foot, causing pain and difficulty walking. Hallux valgus is commonly known as a bunion, involving a bony bump at the base of the big toe. Hammertoe is a condition where one toe is bent abnormally at the middle joint, resembling a hammer. Plantar fasciitis is characterized by pain and inflammation in the arch of the foot, not by a mass causing difficulty walking. Therefore, options A, B, and C are incorrect as they do not describe a mass in the foot leading to difficulty walking, unlike Morton's neuroma.
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Which of the following microorganisms is easily transmitted from client to client on the hands of healthcare workers?
- A. mycobacterium tuberculosis
- B. clostridium tetani
- C. staphylococcus aureus
- D. human immunodeficiency virus
Correct Answer: C
Rationale: The correct answer is staphylococcus aureus. Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail to conduct routine hand washing between clients. Staphylococcus aureus can reside on the skin and be transferred from one client to another if proper hand hygiene is not practiced. Mycobacterium tuberculosis is mainly transmitted through the airborne route, clostridium tetani is usually acquired through exposure to soil or dirt contaminated with tetanus spores, and human immunodeficiency virus is not easily transmitted through casual contact or on the hands of healthcare workers.
Which of the following can certain foods like broccoli, oranges, dark greens, and dark yellow vegetables help improve?
- A. Vitamin intake
- B. Body functions
- C. Defense mechanisms
- D. Disease cure
Correct Answer: C
Rationale: Certain foods like broccoli, oranges, dark greens, and dark yellow vegetables can help improve defense mechanisms by enhancing the immune system and overall health. While these foods can boost defense mechanisms, they are not a cure for diseases, do not balance body functions, and are not intended to solely supplement vitamin intake, which may be necessary in some cases. Therefore, the correct answer is defense mechanisms as these foods strengthen the body's ability to fight off illnesses and maintain health.
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
- A. blood
- B. meconium
- C. hydramnios
- D. caput
Correct Answer: B
Rationale: The correct answer is B: meconium. Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Choice A, blood, is incorrect as blood in the amniotic fluid would present as a different color. Choice C, hydramnios, refers to an excess of amniotic fluid and would not cause the greenish coloration. Choice D, caput, is swelling of a newborn's scalp and is not related to the color of the amniotic fluid.
In alcoholics with anemia:
- A. Pernicious anemia is more common than folic acid deficiency.
- B. Iron deficiency and folic acid deficiency can coexist.
- C. The alcohol interferes with iron absorption.
- D. Oral vitamin replacement is contraindicated.
Correct Answer: B
Rationale: In alcoholics with anemia, iron deficiency and folic acid deficiency can coexist due to poor dietary intake and malabsorption issues associated with chronic alcohol consumption. Pernicious anemia, primarily related to vitamin B12 deficiency, is not commonly seen in alcoholics. While alcohol can interfere with iron absorption, it is not the sole factor contributing to anemia in alcoholics. Oral vitamin replacement is not contraindicated in alcoholics with anemia; however, it may be less effective due to absorption issues related to alcohol consumption.
A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
- A. Within normal limits, so a weight-reduction diet is unnecessary.
- B. Lower than normal, so education about nutrient-dense foods is needed.
- C. Indicating obesity because the BMI is 35.
- D. Indicating overweight status because the BMI is 27.
Correct Answer: C
Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. Body Mass Index (BMI) is calculated by utilizing a chart or nomogram that plots height and weight. In this case, the client's BMI is calculated as 35, indicating obesity. A BMI of 27 falls within the overweight range, not obesity (which starts at 30). Choices A and B are incorrect because a BMI of 35 indicates obesity, not normal limits or being lower than normal. Therefore, the correct answer is C, indicating obesity based on the BMI calculation.