Nokea
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
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A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
- A. Dry skin
- B. Alopecia
- C. Increased salivation
- D. Dolichocephaly
Correct Answer: A
Rationale: The correct answer is A: Dry skin. Malnutrition can lead to a deficiency in essential nutrients like vitamins and minerals, causing skin to become dry and flaky. This occurs due to a lack of proper hydration and nourishment. Alopecia (B) is more commonly associated with conditions like stress or hormonal imbalances. Increased salivation (C) is not typically linked to malnutrition but can be seen in conditions like GERD. Dolichocephaly (D) refers to an elongated shape of the head and is not directly related to malnutrition. In summary, dry skin is a manifestation of malnutrition due to the lack of essential nutrients, while the other choices are more likely associated with different conditions or factors.
A nurse is caring for a client who has a full-thickness burn. Which of the following actions should the nurse take?
- A. Implement fluid restriction.
- B. Provide humidified oxygen.
- C. Administer antibiotic medications.
- D. Administer acyclovir orally.
Correct Answer: B
Rationale: The correct answer is B: Provide humidified oxygen. Full-thickness burns can compromise the client's ability to breathe due to airway swelling and damage. Providing humidified oxygen helps support respiratory function by improving oxygenation and reducing the risk of hypoxia. Implementing fluid restriction (A) is not appropriate as burn patients typically require increased fluid intake to prevent dehydration. Administering antibiotic medications (C) may be necessary to prevent infection but is not the priority in this scenario. Administering acyclovir orally (D) is used to treat viral infections, not full-thickness burns.
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins
- B. Increased blood pressure
- C. Decreased blood pressure
- D. Pitting, dependent edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration in a client with gastroenteritis results in a decrease in blood volume, leading to decreased blood pressure. When the body loses fluids through vomiting and diarrhea, there is a reduction in circulating blood volume, causing a drop in blood pressure. This can result in symptoms such as dizziness, weakness, and increased heart rate as the body tries to compensate for the reduced blood volume. Distended jugular veins (A) are more indicative of heart failure, increased blood pressure (B) can occur in conditions like hypertension or stress, and pitting, dependent edema (D) is a sign of fluid overload, not dehydration.
A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?
- A. I break out in a rash when I eat strawberries.'
- B. I often have diarrhea after eating scrambled eggs.'
- C. I have trouble breathing if I eat acidic foods.'
- D. I sometimes start to wheeze when I eat peanuts.'
Correct Answer: D
Rationale: The correct answer is D because wheezing after consuming peanuts indicates a potential allergic reaction, which could also extend to latex due to cross-reactivity. Peanuts and latex share similar proteins, leading to potential allergic responses. Choices A, B, and C do not indicate a direct correlation to latex allergy and are unrelated symptoms.
A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
- A. Measure blood pressure.
- B. Administer aspirin.
- C. Administer nitroglycerin.
- D. Initiate IV access.
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Aspirin helps to reduce platelet aggregation and prevent further clot formation in clients with acute angina, thus reducing the risk of myocardial infarction. Administering aspirin should be the first action as it addresses the immediate risk of clot formation and helps improve blood flow to the heart muscle.
Measuring blood pressure (A) can be important but is not the priority in this situation. Administering nitroglycerin (C) is important for symptom relief but does not address the underlying cause. Initiating IV access (D) may be necessary later for further interventions, but it is not the first priority.