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A nurse is assessing a client who presents to the provider’s office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy?
- A. Intense pruritus
- B. Irregular borders
- C. Uniform pigmentation
- D. Purulent drainage
Correct Answer: B
Rationale: The correct answer is B: Irregular borders. Irregular borders are a classic sign of malignancy in nevi, suggesting potential melanoma. This finding indicates that the nevus may be evolving into a cancerous lesion. It is crucial for the nurse to report this to the provider promptly for further evaluation. Intense pruritus (choice A) is common in benign nevi and not specific to malignancy. Uniform pigmentation (choice C) is typically seen in benign nevi and is not a concerning feature. Purulent drainage (choice D) is more indicative of infection or inflammation rather than malignancy. In summary, irregular borders are a red flag for malignancy, while the other choices are more likely associated with benign nevi or other conditions.
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A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. WBC count
- B. BUN
- C. Potassium
Correct Answer: A
Rationale: The correct answer is A: WBC count. An elevation in WBC count indicates the presence of infection as the body releases more white blood cells to fight off pathogens. In the case of a pressure ulcer, an increased WBC count suggests bacterial invasion and inflammation at the site of the ulcer. BUN (choice B) and Potassium (choice C) are not specific indicators of infection and are more related to kidney function and electrolyte balance, respectively. Therefore, they are not appropriate for determining infection in this context.
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
- A. Pruritus
- B. Swollen gums
- C. Dysphagia
- D. Urinary hesitancy
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. Dysphagia, difficulty swallowing, is a priority finding in an older adult male as it can lead to aspiration and malnutrition. The nurse needs to address this promptly to prevent complications. Pruritus (choice A) is itching and can be managed. Swollen gums (choice B) may indicate dental issues but are not immediately life-threatening. Urinary hesitancy (choice D) can be indicative of a urinary problem but does not pose an immediate risk compared to dysphagia.
A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?
- A. Tell the client to expect dark stools following chemotherapy.
- B. Have the client swish with commercial mouthwash before therapy.
- C. Administer an antiemetic prior to the procedure.
- D. Have the client floss 4 times daily.
Correct Answer: C
Rationale: The correct answer is C: Administer an antiemetic prior to the procedure. This is important because chemotherapy often causes nausea and vomiting. Administering an antiemetic helps prevent or reduce these side effects, promoting client comfort and compliance with treatment. Choice A is incorrect because dark stools are not a common side effect of chemotherapy for ovarian cancer. Choice B is incorrect as using mouthwash before therapy may not be relevant to chemotherapy administration. Choice D is incorrect as flossing frequency is not directly related to chemotherapy treatment.
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
- A. Obtain a 12-lead ECG.
- B. Suggest that the client use a salt substitute.
- C. Advise the client to add citrus juices and bananas to her diet.
- D. Obtain a blood sample for a serum sodium level.
Correct Answer: A
Rationale: The correct answer is A: Obtain a 12-lead ECG. A potassium level of 6.8 mEq/L indicates hyperkalemia, which can lead to serious cardiac arrhythmias. Therefore, obtaining an ECG is crucial to assess for any potential cardiac abnormalities. Choice B is incorrect as salt substitutes often contain potassium, exacerbating the issue. Choice C is incorrect as citrus juices and bananas are high in potassium, which should be avoided in hyperkalemia. Choice D is incorrect as it focuses on sodium levels, not addressing the immediate concern of hyperkalemia.
A nurse is caring for a client who has delusional behavior and states, 'I can’t go to group therapy today. I am expecting a high-level official to visit me.' The nurse responds, 'I understand, but it is time for group therapy and we expect everyone to attend. Let’s walk over together.' For which of the following reasons is the nurse’s response considered therapeutic?
- A. It clearly articulates the expectations of the client.
- B. It demonstrates empathy towards the client.
- C. It sets limits on the client’s manipulative behavior.
- D. It uses reflection when talking with the client.
Correct Answer: B
Rationale: The correct answer is B: It demonstrates empathy towards the client. By acknowledging the client's feelings and showing understanding, the nurse is building a therapeutic relationship based on empathy. This approach helps the client feel heard and validated, fostering trust and cooperation. The other choices are incorrect because: A) while the response does articulate expectations, it does not address the client's emotions or perspective; C) while setting limits is important, the response does not directly address manipulative behavior; D) reflection involves paraphrasing or summarizing the client's thoughts, which is not evident in the nurse's response.