Nokea
Mandy is a 17-year-old adolescent girl. On physical examination you note partial erosion of her tooth enamel and callus formation on the posterior aspect of the knuckles of her hand. This is indicative of
- A. A connective tissue disorder; she should be referred to dermatology.
- B. Self-induced vomiting; she likely has bulimia nervosa.
- C. Self-mutilation; this correlates with anxiety.
- D. A genetic disorder; her siblings should also be tested.
Correct Answer: B
Rationale: Erosion of tooth enamel and calluses on knuckles are common signs of self-induced vomiting seen in bulimia nervosa.
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Which of the following describes task-oriented touch?
- A. It is used to demonstrate concern or affection.
- B. It involves the contact required for nursing procedures.
- C. The nurse uses task-oriented touch therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: B
Rationale: Task-oriented touch is necessary for performing nursing procedures and ensuring client safety.
Mary has been dieting and exercising daily. Her weight is well below the recommended minimum for her height. Assessment for Mary would include looking for
- A. Ecchymosis and extraocular movements.
- B. Temporal wasting and irregular heart rhythm.
- C. Peripheral edema and rales.
- D. Periorbital edema and chorea.
Correct Answer: B
Rationale: Extreme weight loss can lead to temporal wasting and cardiac irregularities.
A primary nursing responsibility is the prevention of lung cancer by assisting patients in smoking/tobacco cessation. Which task would be appropriate to delegate to the LPN/LVN?
- A. Develop a 'quit plan'.
- B. Discuss strategies to avoid relapse.
- C. Explain the application of a nicotine patch.
- D. Suggest ways to deal with urges for tobacco.
Correct Answer: C
Rationale: Explaining the application of a nicotine patch is a technical task that LPNs/LVNs can perform, while developing plans or discussing strategies require more specialized knowledge.
In a client diagnosed with superficial mycotic infections, which of the following should the nurse closely monitor for infection?
- A. Eyes and ears
- B. Skin,hair and nails
- C. Subcutaneous tissues
- D. Mouth and teeth
Correct Answer: B
Rationale: The correct answer is B because superficial mycotic infections primarily affect the skin, hair, and nails, making these areas critical to monitor.
Which of the following tasks is most appropriate to delegate to the nursing assistant?
- A. Escort the family to a place of privacy
- B. Go with the organ donor specialist to talk to the family
- C. Assist with postmortem care
- D. Assist the family to collect belongings
Correct Answer: C
Rationale: Postmortem care involves basic hygiene and positioning, which can be performed by a nursing assistant.