Nokea
A nurse is assisting with preventive health screenings at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply.
- A. For the past few years, I get a productive cough in the winter that goes away in the spring
- B. I occasionally have heartburn an hour after I eat fried foods and sausage.
- C. Last month when I was doing my breast self-examination, I noticed a marble-sized lump.
- D. My mole is itchy, and the edges have become uneven with a blackish to bluish color.
- E. Recently I have noticed that my bowel movements appear black.
Correct Answer: C,D,E
Rationale: A breast lump, an asymmetrical/irregular mole, and black stools are potential cancer signs (breast cancer, melanoma, gastrointestinal cancer). Seasonal cough and occasional heartburn are less concerning.
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The physician has ordered a minimal bacteria diet on a client with neutropenia. Which seasoning is not permitted for this client?
- A. Salt
- B. Lemon juice
- C. Pepper
- D. Ketchup
Correct Answer: C
Rationale: A minimal bacteria diet for neutropenic clients avoids foods that may harbor bacteria, such as raw or undercooked foods and certain seasonings like pepper, which can contain mold or bacteria. Salt , lemon juice , and ketchup are generally processed and less likely to pose a bacterial risk.
The nurse is teaching a group of women about health issues. Today's topic is food poisoning. Which statement indicates a need for further instruction?
- A. I always wash my hands after I put raw meat in to cook.'
- B. I should put foods away in the refrigerator immediately after meals.'
- C. I will wash my kitchen counters with a bleach solution after preparing raw meat.'
- D. Rare meat is okay to eat as long as it is eaten immediately after cooking.'
Correct Answer: D
Rationale: Rare meat poses a risk for foodborne pathogens like E. coli, even if eaten immediately. Other statements reflect proper food safety practices.
The nurse is caring for a client born at 42 weeks gestation. Which of the following potential clinical findings should the nurse anticipate for a postterm newborn? Select all that apply.
- A. Deep plantar creases
- B. Dry, cracked, peeling skin
- C. Lanugo on the extremities
- D. Long fingernails and scalp hair
- E. Minimal or absent vernix
Correct Answer: A,B,D,E
Rationale: Postterm newborns often have deep plantar creases, dry/peeling skin, long nails/hair, and minimal vernix due to prolonged gestation. Lanugo is more common in preterm infants.
To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the
- A. Finger and toenail quicks
- B. Eyes
- C. Perianal area
- D. External ear canals
Correct Answer: B
Rationale: Eyes. Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch.
A client has had a positive reaction to purified protein derivative (PPD). The client asks the nurse what this means. The nurse should indicate that the client has
- A. active tuberculosis
- B. been exposed to mycobacterium tuberculosis
- C. never had tuberculosis
- D. never been infected with mycobacterium tuberculosis
Correct Answer: B
Rationale: The PPD skin test is used to determine the presence of tuberculosis antibodies and a positive result indicates that the person has been exposed to mycobacterium tuberculosis. Additional tests are needed to determine if active tuberculosis is present.