Nokea
A nurse assisting with data collection notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding using which term?
- A. Ptosis
- B. Nystagmus
- C. Scleral icterus
- D. Exophthalmos
Correct Answer: B
Rationale: When a nurse observes rapid, involuntary oscillating movements of the eyeball in a client, this is described as nystagmus. Nystagmus appears as a fine oscillating movement, most notable around the iris. It is important to assess for nystagmus when evaluating ocular muscle weakness. Mild nystagmus at extreme lateral gaze is considered normal; nystagmus in any other position is not. Ptosis refers to a drooping of the eyelid, not rapid eye movements. Scleral icterus is the yellowing of the sclera up to the cornea, indicating jaundice, not related to eye movements. Exophthalmos is a noticeable protrusion of the eyeball, typically seen in hyperthyroidism, not associated with rapid oscillating eye movements.
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A 37-year-old female client asks the nurse about contraception options and expresses interest in oral contraception pills. Which of the following statements would indicate that oral contraception is appropriate for this client?
- A. "I quit smoking last year, but I started again recently. Maybe I'll try to quit later this year."?
- B. "I am very diligent in taking my thyroid medications at the same time every day."?
- C. "I was hospitalized for deep vein thrombosis five years ago."?
- D. "I was recently diagnosed with breast cancer."?
Correct Answer: C
Rationale: The correct answer is the statement mentioning a history of deep vein thrombosis five years ago. Oral contraceptives are generally not recommended for individuals with a history of deep vein thrombosis due to the increased risk of blood clots. Choice B, about being diligent in taking thyroid medications, does not directly relate to the safety of using oral contraceptives. Choice D, about a recent breast cancer diagnosis, would contraindicate the use of hormonal contraceptives. Choice A, mentioning a recent return to smoking, raises concerns about using hormonal contraceptives due to the increased risk of cardiovascular complications.
A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Health promotion
Correct Answer: A
Rationale: Primary prevention involves activities that promote wellness or prevent illness or injury. Educating parents about safety measures in the home aims to prevent injuries, making it a primary prevention strategy. Secondary prevention focuses on early detection and intervention in diseases or injuries. Tertiary prevention involves reducing disability and promoting optimal functioning in relation to a disease or injury. Health promotion encompasses activities that enhance a client's overall health and well-being. In this scenario, educating parents about safety in the home falls under primary prevention as it aims to prevent injuries before they occur.
All of the following factors, when identified in the history of a family, are correlated with poverty except:
- A. high infant mortality rate
- B. frequent use of Emergency Departments
- C. consultation with folk healers
- D. low incidence of dental problems
Correct Answer: D
Rationale: Factors correlated with poverty often include a high infant mortality rate, frequent use of Emergency Departments, and consultation with folk healers, as these indicate limited access to healthcare. Dental problems are prevalent in poverty due to a lack of preventive care and access to treatments. High infant mortality is a significant issue linked with poverty as it reflects poor healthcare access. Families in poverty might resort to Emergency Departments for healthcare due to financial barriers. Consulting folk healers is common in communities with limited access to formal healthcare. However, a low incidence of dental problems is less likely in impoverished families due to the lack of preventive services and the presence of other health issues.
A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?
- A. Asking the client to stick out his or her tongue and watching for tremors
- B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex
- C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah'
- D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands
Correct Answer: D
Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size and strength. The correct method involves asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands. Choice A, asking the client to stick out the tongue and watching for tremors, is used to assess cranial nerve XII (hypoglossal nerve). Choice C, depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah', is the technique for examining cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Choice B, touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex, is used to evaluate cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve), not cranial nerve XI.
At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she makes which statement?
- A. BSE should be performed monthly after the menstrual period.
- B. BSE is performed after the menstrual period.
- C. Monthly BSE is a recommended method for early detection of breast cancer.
- D. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.
Correct Answer: D
Rationale: The correct answer is 'Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.' BSE should be performed monthly after the menstrual period, not every other month or on the day menstruation begins. Performing BSE on the seventh day of the menstrual cycle when the breasts are smallest and least congested is recommended. While BSE is a useful tool for early detection, it is not the only method. Regular physical examinations and mammograms are also important. The correct technique for BSE includes inspecting the breasts in front of a mirror, palpating in the shower for easier detection, and conducting palpation while lying down for thorough examination.