Nokea
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
- A. Eating a high fiber diet will reduce my risk for developing skin cancer.
- B. I should check my skin monthly for any changes.
- C. I should avoid the use of tanning booths.
- D. I should use sunscreen even on cloudy days.
- E. I should use sunscreen even on cloudy days.
Correct Answer: A
Rationale: The correct answer is A. Eating a high fiber diet does not directly reduce the risk of developing skin cancer. The other choices are more directly related to preventing skin cancer, such as checking skin for changes (B), avoiding tanning booths (C), and using sunscreen on both sunny and cloudy days (D and E). Therefore, further teaching is needed to clarify the misconception about the role of a high fiber diet in preventing skin cancer.
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When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?
- A. Flank pain with radiation to the groin, accompanied by hematuria.
- B. Respiratory distress, chest pain, and use of accessory muscles.
- C. Crackles, peripheral edema, and weight gain.
- D. Confusion, decreasing level of consciousness, and aphasia.
Correct Answer: C
Rationale: The correct answer is C: Crackles, peripheral edema, and weight gain. In infective endocarditis, there is a risk of developing heart failure due to damage to the heart valves. Monitoring for crackles indicates fluid accumulation in the lungs, a sign of left-sided heart failure. Peripheral edema is a result of right-sided heart failure, which can occur in infective endocarditis. Weight gain is a common symptom of heart failure due to fluid retention. Flank pain with radiation to the groin and hematuria (choice A) are more indicative of kidney issues rather than heart failure. Respiratory distress, chest pain, and use of accessory muscles (choice B) are more suggestive of acute pulmonary conditions. Confusion, decreasing level of consciousness, and aphasia (choice D) are symptoms of neurological issues, not heart failure.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
- A. Friction rub.
- B. Intermittent claudication.
- C. Cardiac murmur.
- D. Dependent rubor.
Correct Answer: C
Rationale: The correct answer is C: Cardiac murmur. Endocarditis is an infection of the inner lining of the heart chambers and valves, which can lead to the development of a new murmur due to valve damage or vegetation formation. This can result in turbulent blood flow, causing the murmur. A friction rub (choice A) is more indicative of pericarditis, intermittent claudication (choice B) is associated with peripheral arterial disease, and dependent rubor (choice D) is seen in chronic arterial insufficiency. Therefore, recognizing a new cardiac murmur in a client with endocarditis is crucial as it can indicate complications such as valve dysfunction or embolic events.
A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
- A. Unilateral joint involvement.
- B. Ulnar deviation.
- C. Decreased sedimentation rate.
- D. Fractures of the spine.
Correct Answer: B
Rationale: The correct answer is B: Ulnar deviation. In rheumatoid arthritis, ulnar deviation of the fingers is a common finding due to inflammation and destruction of the joints. This deformity leads to the fingers deviating towards the ulnar side of the hand. This is a characteristic feature seen in rheumatoid arthritis and is caused by the inflammation affecting the joints. Choices A, C, and D are incorrect. A: Unilateral joint involvement is not typical of rheumatoid arthritis, as it usually affects multiple joints symmetrically. C: Decreased sedimentation rate is not expected in rheumatoid arthritis, as it is typically associated with an elevated sedimentation rate due to inflammation. D: Fractures of the spine are not a common finding in rheumatoid arthritis, as it primarily affects the joints.
A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
- A. Potassium level.
- B. Prealbumin level.
- C. History of diabetes mellitus.
- D. History of hyperlipidemia.
- E. Wound infection.
- F. Decreased pedal perfusion.
- G. Fasting blood glucose.
Correct Answer: B,C,E,F,G
Rationale: The correct answer choices (B, C, E, F, G) can cause delayed wound healing due to specific reasons.
B: Prealbumin level reflects protein status, crucial for wound healing.
C: Diabetes mellitus impairs circulation and immune response, affecting healing.
E: Wound infection introduces pathogens, prolonging inflammation and delaying healing.
F: Decreased pedal perfusion reduces oxygen and nutrient delivery to the wound site.
G: Elevated fasting blood glucose hinders immune cell function and collagen synthesis.
Incorrect choices (A, D) are not directly linked to wound healing delays. Potassium level (A) mainly affects cardiac and muscle function, and hyperlipidemia (D) primarily impacts cardiovascular health, not wound healing directly.
A nurse is caring for an 84-year-old male client in the medical unit. The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
- A. Teach the client about the condition.
- B. Encourage intake of low-sodium diet.
- C. Administer prescribed medications.
- D. Monitor vital signs regularly.
- E. Schedule a follow-up appointment with a specialist.
- F. Anemia
- G. Blood pressure
Correct Answer: A,C,D,E
Rationale: The correct answer is A,C,D,E. Firstly, the client is likely experiencing anemia based on the symptoms of fatigue, dizziness, and shortness of breath. Therefore, administering prescribed medications (C) to address the anemia is crucial. Teaching the client about the condition (A) helps improve understanding and compliance. Monitoring vital signs (D) is essential to track the client's response to treatment. Scheduling a follow-up appointment with a specialist (E) ensures ongoing evaluation and management. Encouraging intake of a low-sodium diet (B) is not directly related to anemia and may not be the priority in this case. Blood pressure (G) monitoring is important but not specific to anemia.