A nurse is caring for a client diagnosed with peripheral artery disease. Which of the following is a common assessment finding?
- A. 4+ pedal pulses
- B. 3+ pedal pulses
- C. Bounding pulses in all 4 extremities
- D. 1+ pedal pulses
Correct Answer: D
Rationale: Peripheral artery disease (PAD) clogs arteries, slashing flow 1+ pedal pulses (weak, thready) are typical, reflecting ischemia below blockages. 4+ or 3+ pulses (strong) contradict PAD's hypoperfusion; bounding pulses suggest hyperdynamic states, not occlusion. Nurses expect weak pulses, checking for pain or pallor, key to tracking PAD's limb-threatening march, guiding interventions like revascularization.
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An HIV-positive patient presents to the ED complaining of shortness of breath and non-productive cough. Chest x-ray shows diffuse interstitial infiltrates, and O2 saturation is 85% on room air. All of the following statements regarding this patient's probable diagnosis are TRUE, EXCEPT
- A. Pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection in AIDS patients
- B. Pentamidine isothionate is an effective alternate therapy to TMP-SMX
- C. A normal chest x-ray rules out acute PCP infection
- D. 65% of patients relapse within 18 months
Correct Answer: H
Rationale: PCP top AIDS bug, pentamidine swaps TMP-SMX, relapse hits, steroids for hypoxia; normal CXR misses 20%. Nurses nix this chronic x-ray lie.
Which of the following health determinants is NOT a component of Lalonde's model?
- A. Biological factors
- B. Physical environment
- C. Health care
- D. Attitude to life
Correct Answer: D
Rationale: Lalonde's grid biology, environment, care, not attitude shapes health, not mindsets. Nurses map this, a chronic model cut.
For care of a patient who has oral cancer, which task would be appropriate to delegate to the LPN/LVN?
- A. Assist the patient to brush and floss
- B. Explain when brushing and flossing are contraindicated
- C. Give antacids and sucralfate suspension as ordered
- D. Recommend saliva substitutes
Correct Answer: C
Rationale: LPN/LVNs excel in medication administration within their scope, making giving antacids and sucralfate ordered for oral cancer's mucosal protection ideal. Brushing and flossing assistance fits nursing assistants, a basic task. Explaining contraindications requires RN-level judgment to assess risks like bleeding or infection. Recommending saliva substitutes needs physician or pharmacist input, beyond LPN/LVN authority. Medication delivery leverages their training, easing symptoms like pain or ulcers, ensuring safe, supervised care in oral cancer's complex management, a practical delegation choice.
Patients on insulin therapy should receive essential education on the following EXCEPT:
- A. Insulin injection technique
- B. Recognition and self-management of hypoglycaemia
- C. Sick day management
- D. Stopping all oral hypoglycaemic agents
Correct Answer: D
Rationale: Insulin education builds control technique, hypo spotting, sick days, and driving safety are musts, ensuring delivery, crisis handling, and road smarts. Stopping all oral agents isn't universal; many stay on metformin or SGLT-2s for synergy, not a blanket rule. Tailored plans keep or ditch orals, dodging this absolute. Clinicians teach what fits, not a one-size purge, a nuanced chronic care tweak over rigid cuts.
A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
- A. Benign tumors do not cause damage to other tissues.
- B. Benign tumors are likely to recur in the same location.
- C. Malignant tumors may spread to other tissues or organs.
- D. Malignant cells reproduce more rapidly than normal cells.
Correct Answer: C
Rationale: Malignant tumors metastasize spreading to distant sites via lymph or blood unlike benign ones, which stay put. That's the key split. Benign tumors can still mess up nearby tissues by pressing on them (e.g., a benign meningioma squeezing brain), so A's off. B's wrong benign tumors rarely recur if fully removed; malignancy's more prone to that. D's a myth malignant cells don't always divide faster; some, like chronic leukemia, creep along. Nurses in oncology nail this down for patients facing biopsies, like this breast case, where fear of spread drives the question. Explaining metastasis clarifies why malignant's scarier it's not just growth, it's invasion, a game-changer for prognosis and treatment.