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During a routine health screening, the nurse should talk to the parents of a 1-year-old child about which of the following?
- A. the potential hazards of accidents
- B. appropriate nutrition now that the child has been weaned from breastfeeding
- C. toilet training
- D. how to prevent accidents in the house
Correct Answer: A
Rationale: During a routine health screening for a 1-year-old child, discussing the potential hazards of accidents is crucial. Accidents are the primary source of injury in children and can be life-threatening. Addressing appropriate nutrition now that the child has been weaned from breastfeeding should have already been discussed. Toilet training is important but is typically addressed at a later age as one year is too early for this milestone. While preventing accidents in the house is important, focusing on the potential hazards of accidents in general is more comprehensive and critical for the child's safety.
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A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:
- A. increased ferning capacity.
- B. lack of ferning.
- C. spinnbarkheit.
- D. inhospitable.
Correct Answer: C
Rationale: The nurse should document the finding as 'spinnbarkheit.' Spinnbarkheit is the term used to describe the clear, thin, and elastic cervical mucus that can be stretched 8-10 cm, indicating ovulation. It helps couples determine the most fertile period for conception. Ferning capacity or crystallization increases as ovulation approaches, but it requires microscopic examination to be confirmed. Lack of ferning cannot be determined without such examination. 'Inhospitable' cervical mucus refers to patterns that prohibit sperm motility, caused by various factors like hormone levels or infection. These conditions cannot be assessed based solely on the description provided in the question.
A client asks the nurse what risk factors increase the chances of getting skin cancer. The risk factors include all except:
- A. light or fair complexion.
- B. exposure to sun for extended periods of time.
- C. certain diet and foods.
- D. history of bad sunburns.
Correct Answer: C
Rationale: The correct answer is 'certain diet and foods.' Risk factors that increase the chances of getting skin cancer include having a light or fair complexion, a history of bad sunburns, personal or family history of skin cancer, outdoor activities with sun exposure, exposure to X-rays or radiation, exposure to certain chemicals, repeated trauma or injury resulting in scars, age over 50, male gender, and living in specific geographic locations. These factors can contribute to the development of skin cancer. Avoiding exposure to the sun, using protective clothing and sunscreen, and regular skin inspections are key preventive measures. Choice C, 'certain diet and foods,' is incorrect as diet is not a primary risk factor for skin cancer. Options A, B, and D are all valid risk factors associated with an increased risk of developing skin cancer.
During a throat assessment, a healthcare provider asks a client to stick out their tongue and notices it protrudes in the midline. Which cranial nerve is being tested?
- A. Cranial nerve X
- B. Cranial nerve V
- C. Cranial nerve IX
- D. Cranial nerve XII
Correct Answer: D
Rationale: The correct answer is cranial nerve XII (hypoglossal nerve). When testing cranial nerve XII, the healthcare provider inspects the symmetry and movement of the tongue. The tongue should protrude in the midline when the client sticks it out. Cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve) are tested by depressing the tongue with a blade to observe pharyngeal movement and gag reflex. Cranial nerve V (trigeminal nerve) is responsible for testing the muscles of mastication, not tongue protrusion.
While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?
- A. Hypoactive bowel sounds
- B. Low-pitched bowel sounds
- C. Hyperactive bowel sounds
- D. An absence of bowel sounds
Correct Answer: C
Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.
When performing the confrontation test to assess peripheral vision, what action should the nurse take?
- A. Asks the client to identify a small object brought into the visual field
- B. Has the client cover one eye while the nurse covers one eye and slowly advances a target midline between them
- C. Covers one eye, while the client covers the opposite eye, and brings a small object into the visual field
- D. Positions at eye level with the client, covers one eye, and has the client cover the opposite eye, then brings a small object into the visual field
Correct Answer: D
Rationale: When performing the confrontation test to assess peripheral vision, the nurse should position at eye level with the client, cover one eye, and have the client cover the opposite eye. This approach allows the examiner to bring a small object into the visual field to evaluate the client's peripheral vision. The test aims to compare the client's peripheral vision with the examiner's vision to identify any visual field deficits. Choices A, B, and C are incorrect. Choice A pertains to testing color vision, which is not part of the confrontation test. Choice B describes a different procedure that involves advancing a target midline between the client and examiner, not the correct approach for the confrontation test. Choice C is inaccurate as it fails to include the essential step of positioning at eye level with the client, making it an incorrect representation of the confrontation test.