Nokea
At a public health fair, a nurse discusses the dangers of sun exposure. Prolonged sun exposure has been blamed for which form of cancer?
- A. Malignant melanoma
- B. Basal cell epithelioma
- C. Squamous cell carcinoma
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, "All of the above." Malignant melanoma, basal cell epithelioma, and squamous cell carcinoma are all types of skin cancer associated with prolonged sun exposure. Melanoma is the most dangerous form, while basal cell and squamous cell carcinomas are more common but less aggressive. Sun exposure can lead to DNA damage in skin cells, increasing the risk of developing these types of cancers. Therefore, all three choices are correct as they are all linked to sun exposure. The other choices are incorrect because each type of skin cancer mentioned can be caused by prolonged sun exposure, so selecting any one of them individually would not fully capture the scope of the risks associated with sun exposure.
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Which of the following is information the nurse would be correct in giving the patient about smoking and its effect on BP?
- A. It is associated with stages 1 and 2 hypertension.
- B. It does not affect BP regulation.
- C. It vasodilates the peripheral blood vessels.
- D. It causes sustained BP elevation.
Correct Answer: A
Rationale: The correct answer is A: It is associated with stages 1 and 2 hypertension. Smoking is a major risk factor for developing hypertension, especially stages 1 and 2. Nicotine in cigarettes can lead to vasoconstriction, increased heart rate, and overall elevated blood pressure. This information is crucial for patients to understand the direct impact of smoking on their blood pressure levels.
Choice B is incorrect because smoking does indeed affect BP regulation by causing vasoconstriction and elevated heart rate. Choice C is incorrect as smoking actually causes vasoconstriction rather than vasodilation. Choice D is incorrect because smoking does lead to sustained elevation of blood pressure, especially in the long term.
A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
- A. Wash the area with soap and warm water
- B. Leave the skin alone until it is clear
- C. Apply a cream or lotion to the area
- D. Avoid applying creams or lotion to the area
Correct Answer: C
Rationale: The correct answer is C: Apply a cream or lotion to the area. This is because radio-dermatitis is a common side effect of radiation therapy, causing skin irritation and dryness. Applying a cream or lotion helps to moisturize the skin, reduce inflammation, and promote healing. Washing the area with soap can further irritate the skin. Leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions can worsen dryness and discomfort. Overall, applying a suitable cream or lotion is the most effective method to alleviate symptoms and support skin recovery in radio-dermatitis.
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
- A. Risk
- B. Problem focused
- C. Health promotion
- D. Collaborative problem
Correct Answer: C
Rationale: The correct answer is C: Health promotion. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition.
Incorrect choices:
A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it.
B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed.
D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.
A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority?
- A. The need to have nutrition
- B. The need to feel good about oneself
- C. The need to live in a safe environment
- D. The need for love from others
Correct Answer: B
Rationale: The correct answer is B: The need to feel good about oneself. This is the priority because the resident's refusal to eat is tied to her desire to maintain her personal appearance and feel good about herself. By addressing this need first, the resident may become more willing to eat. The other choices are incorrect because while nutrition (A) is important, addressing the resident's self-esteem and well-being should come first. The need to live in a safe environment (C) is also important but not the priority in this specific scenario. The need for love from others (D) is significant but not directly related to the resident's refusal to eat based on her personal grooming preferences.
The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketonic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
- A. Elevated serum acetone level
- B. Serum alkalosis
- C. Serum ketone bodies
- D. Below-normal serum potassium level
Correct Answer: D
Rationale: Step 1: In HHNS, there is severe hyperglycemia leading to osmotic diuresis.
Step 2: Osmotic diuresis causes loss of potassium in urine, leading to hypokalemia.
Step 3: Hypokalemia is a common electrolyte imbalance in HHNS due to excessive urinary loss of potassium.
Step 4: Therefore, the nurse should anticipate a below-normal serum potassium level in a client with HHNS.
Summary:
A: Elevated serum acetone level is seen in diabetic ketoacidosis, not HHNS.
B: Serum alkalosis is not typically associated with HHNS.
C: Serum ketone bodies are elevated in diabetic ketoacidosis, not HHNS.