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: Prolonged sun exposure is indeed a known risk factor for all three types of skin cancer listed in the choices. Malignant melanoma is a serious form of skin cancer that develops in the melanocytes, the cells that produce skin pigment. Basal cell epithelioma and squamous cell carcinoma are two other common types of skin cancer that are largely attributed to sun exposure. It is crucial to protect your skin from the harmful effects of the sun by applying sunscreen, wearing protective clothing, and seeking shade when necessary to reduce the risk of developing skin cancer.
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A client with colon cancer requires a permanent colostomy because of the tumor location. After surgery, the client must learn how to irrigate the colostomy. When irrigating, how far into the stoma should the client insert the lubricated catheter?
- A. 0.25" to 0.5"
- B. 2" to 4"
- C. 1" to 1.5"
- D. 5" to 7"
Correct Answer: C
Rationale: When irrigating a colostomy, the client should insert the lubricated catheter approximately 1 to 1.5 inches (2.5 to 4 cm) into the stoma. This depth ensures that the catheter reaches the optimal level within the colon to effectively irrigate and cleanse the colon contents. Inserting the catheter too shallow may not reach the colon, while inserting it too deep can cause discomfort or injury to the lining of the colon. It is important for the client to be educated on the correct technique and depth for colostomy irrigation to maintain bowel regularity and health.
While caring for a critically ill child, the nurse observes that respirations are gradually increasing in rate and depth, with periods of apnea. What pattern of respiration will the nurse document?
- A. Dyspnea
- B. Tachypnea
- C. Cheyne-Stokes respirations
- D. Seesaw (paradoxic) respirations
Correct Answer: C
Rationale: Cheyne-Stokes respirations are characterized by alternating periods of deep, rapid breathing followed by periods of apnea. This cyclic pattern of respiration is often seen in critically ill patients and can be a sign of serious neurological or cardiac dysfunction. The nurse should document Cheyne-Stokes respirations when observing this specific breathing pattern in the child described in the scenario.
An infant has been diagnosed with cow's milk allergy. What are the clinical manifestations the nurse expects to assess? (Select all that apply.)
- A. Pink mucous membranes
- B. Vomiting
- C. Rhinitis
- D. Abdominal pain
Correct Answer: B
Rationale: Pink mucous membranes are not a typical clinical manifestation of cow's milk allergy. Allergies often present with symptoms affecting the gastrointestinal tract, respiratory system, skin, or a combination of these systems.
. A client with a suspected left sided heart failure is scheduled to undergo a multigated acquisition scan. Which of the following actions is required before undergoing the test?
- A. Diuretics are administered
- B. Client should avoid fluid intake 6 hours
- C. Client is medicated to relieve cough before the test
- D. Client is administered analgesics
Correct Answer: C
Rationale: Before undergoing a multigated acquisition scan, a client with suspected left sided heart failure should be medicated to relieve cough. Coughing can disrupt the accuracy of the scan results by affecting the heart's movement and leading to motion artifacts. Therefore, it is essential to address any coughing issues before the test to ensure reliable and accurate imaging of the heart's function. The other options, such as administering diuretics, avoiding fluid intake, and administering analgesics, are not directly related to optimizing the imaging quality of the multigated acquisition scan for a client with suspected left sided heart failure.
In which of the ff clients will an MRI scan be contraindicated?
- A. Overweight clients
- B. Clients with metal implants in their body
- C. Clients over the age of 60
- D. Clients with brain tumor CARING FOR CLIENTS WITH CENTRAL AND PERIPHERAL NERVOUS SYSTEM DISORDERS
Correct Answer: B
Rationale: An MRI scan uses strong magnetic fields and radio waves to create detailed images of the body's internal structures. Clients with metal implants in their body, such as pacemakers, artificial joints, or other metallic objects, may experience potential risks and complications during an MRI scan. The strong magnetic field can interact with the metal in the body, causing movement, heating, or potential damage to the surrounding tissues. Hence, it is contraindicated to perform an MRI scan on clients with metal implants to avoid harm and ensure their safety.