A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the clients skin?
- A. A pearly, waxy nodule
- B. A scaly, red patch
- C. A dark, irregular mole
- D. A firm, painless lump
Correct Answer: A
Rationale: The correct answer is A: A pearly, waxy nodule. Basal cell carcinoma typically presents as a pearly, waxy nodule on the skin. This characteristic appearance is due to the growth of abnormal cells in the basal cell layer of the skin. The nodule may also have small blood vessels visible on its surface. This presentation is distinct from other skin lesions. Choice B, a scaly red patch, is more indicative of conditions like psoriasis or eczema. Choice C, a dark irregular mole, is more suggestive of melanoma. Choice D, a firm, painless lump, is more characteristic of conditions like lipomas or fibromas. Thus, the correct answer is A based on the specific characteristics of basal cell carcinoma.
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A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching?
- A. Walk 30 min daily at a comfortable pace.
- B. Avoid all sources of dietary fat.
- C. Increase sodium intake to prevent dehydration.
- D. Only exercise if experiencing symptoms.
Correct Answer: A
Rationale: Correct Answer: A: Walk 30 min daily at a comfortable pace.
Rationale: Regular physical activity, such as walking, helps prevent coronary artery disease by improving cardiovascular health, maintaining a healthy weight, and reducing stress. Walking for 30 minutes daily at a comfortable pace can improve circulation, lower blood pressure, and reduce the risk of developing heart disease.
Summary of other choices:
B: Avoiding all sources of dietary fat is not recommended as the body needs healthy fats for various functions.
C: Increasing sodium intake does not prevent coronary artery disease and can actually contribute to hypertension, a risk factor for the disease.
D: Only exercising when experiencing symptoms is not proactive in preventing coronary artery disease and may lead to missed opportunities for prevention.
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the clients coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?
- A. Notify risk management.
- B. Inform the transferring agency of the clients condition.
- C. Contact the family regarding the clients condition.
- D. Privately interview the client about the injuries.
Correct Answer: D
Rationale: Correct Answer: D - Privately interview the client about the injuries.
Rationale:
1. As a healthcare provider, the nurse must prioritize the well-being and safety of the client.
2. Privately interviewing the client allows for a confidential conversation to gather information directly from the client.
3. This approach respects the client's autonomy and confidentiality.
4. It enables the nurse to assess the situation, gather more details, and determine if further actions are needed to address the suspected elder abuse.
5. Notifying risk management (A) is important but should come after gathering information from the client.
6. Informing the transferring agency (B) may not address the immediate concern of potential abuse.
7. Contacting the family (C) may not be appropriate if they are involved in the abuse.
8. Failing to interview the client may result in a missed opportunity to address the issue effectively.
Summary:
Option D is correct as it prioritizes the client's well-being, respects autonomy, and
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect?
- A. Low urine specific gravity
- B. High urine specific gravity
- C. Elevated potassium levels
- D. Decreased potassium levels
Correct Answer: A
Rationale: The correct answer is A: Low urine specific gravity. Excessive diuretic use can lead to volume depletion and low sodium levels. Low sodium levels cause the kidneys to excrete more water, resulting in dilute urine with low specific gravity. High urine specific gravity would indicate concentrated urine, which is not expected in this situation. Elevated potassium levels (choice C) are not typically associated with overuse of diuretics, as diuretics can actually lead to potassium loss. Similarly, decreased potassium levels (choice D) are commonly seen with diuretic use due to increased excretion of potassium by the kidneys.
A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect heavy bleeding for the next week.
- B. I will avoid using tampons for the next few weeks.
- C. I should resume sexual activity within 24 hours.
- D. I will avoid all physical activity for a month.
Correct Answer: B
Rationale: The correct answer is B: "I will avoid using tampons for the next few weeks." This statement indicates an understanding of the discharge teaching because using tampons can introduce bacteria into the healing cervix, increasing the risk of infection post-LEEP. Choosing this answer demonstrates knowledge of the importance of maintaining good hygiene and minimizing infection risk during the healing process.
Other choices are incorrect:
A: Expecting heavy bleeding for the next week is incorrect as heavy bleeding should decrease gradually.
C: Resuming sexual activity within 24 hours is incorrect as it can increase the risk of infection and disrupt the healing process.
D: Avoiding all physical activity for a month is incorrect as light activities are usually allowed, and complete inactivity can lead to complications like blood clots.