Nokea
The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
- A. Actinic
- B. Asymmetry
- C. Arcus
- D. Assessment
Correct Answer: B
Rationale: The correct answer is B: Asymmetry. In the ABCD method for assessing skin lesions, A stands for asymmetry, which refers to whether one half of the lesion looks different from the other half. This is important because asymmetrical lesions are more likely to be cancerous. Actinic (choice A) refers to sun damage, Arcus (choice C) refers to a condition affecting the eyes, and Assessment (choice D) is a general term that does not specifically relate to the characteristics of skin lesions.
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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. The nurse wrote a diagnosis of Readiness for enhanced urinary elimination, which indicates the patient's willingness to improve their urinary elimination abilities. Health promotion diagnoses focus on improving the client's well-being and enhancing their health potential. In this scenario, the patient's desire to learn self-catheterization aligns with health promotion as it involves empowering the patient to take an active role in their care.
Choice A (Risk) is incorrect because the patient is not currently at risk for urinary elimination issues, but rather seeking to enhance their abilities. Choice B (Problem focused) is incorrect as the diagnosis is not about addressing a current problem but rather focusing on potential improvement. Choice D (Collaborative problem) is incorrect as it does not involve collaboration between healthcare providers but rather focuses on the patient's readiness and willingness to enhance their own health outcomes.
The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
- A. Space the administration every 4 hours.
- B. Use the drug for a short time only
- C. Take piroxicam with food or oral antacid
- D. Decrease the piroxicam dosage
Correct Answer: C
Rationale: The correct answer is C: Take piroxicam with food or oral antacid. This instruction helps to reduce GI irritation by providing a protective barrier for the stomach lining. Piroxicam is known to cause GI upset due to its effect on prostaglandin synthesis. Taking it with food or an antacid can help minimize this side effect.
Choice A (Space the administration every 4 hours) does not address the issue of GI irritation and is not a recommended strategy for preventing this side effect.
Choice B (Use the drug for a short time only) is not a direct intervention to prevent GI upset and does not provide guidance on how to manage the side effect when taking the medication.
Choice D (Decrease the piroxicam dosage) may not be necessary if the client can manage the side effects with the simple intervention of taking it with food or an antacid.
A client asks the nurse what PSA is. The nurse should reply that is stands for:
- A. Prostate-specific antigen, which is used to screen for prostate cancer
- B. Protein serum antigen, which is used to determine protein levels
- C. Pneumococcal strep antigen, which is bacteria that causes pneumonia
- D. Papanicolua-specific antigen, which is used to screen for cervical cancer
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Prostate-specific antigen (PSA) is a protein produced by the prostate gland. It is primarily used to screen for prostate cancer by measuring the levels of PSA in the blood. PSA levels can help detect prostate cancer early. Therefore, choice A is the correct answer as it accurately describes PSA and its primary use.
Summary of Incorrect Choices:
B: Protein serum antigen is not a commonly known term in healthcare. There is no specific antigen called "protein serum antigen" used to determine protein levels.
C: Pneumococcal strep antigen is a bacterial antigen that causes pneumonia, not related to PSA used in prostate cancer screening.
D: Papanicolua-specific antigen is not a recognized term. The Papanicolaou test (Pap smear) is used for cervical cancer screening, not a specific antigen like PSA.
A client who is HIV positive should have the mouth examined for which oral problem common associated with AIDS?
- A. Halitosis
- B. Creamy white patches
- C. Carious teeth
- D. Swollen lips
Correct Answer: B
Rationale: The correct answer is B: Creamy white patches. These patches are indicative of oral thrush, a common fungal infection seen in individuals with weakened immune systems like those with AIDS. This infection is caused by Candida albicans. It presents as white patches on the tongue, inner cheeks, or roof of the mouth. Halitosis (A) is bad breath, not specific to AIDS. Carious teeth (C) refers to cavities, not directly related to AIDS. Swollen lips (D) can be a symptom of various oral conditions, but not specific to AIDS. In summary, creamy white patches are a characteristic oral problem associated with AIDS due to opportunistic infections like oral thrush.
A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?
- A. Request that the family leave, so the patient can rest.
- B. Ask the patient to return to the room, so the nurse can inspect the abdomen.
- C. Ask the patient when the last bowel movement was and to lie down on the sofa. Tell the patient that the dinner tray will be ready in 15 minutes and that may help
- D. the stomach feel better.
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen.
Rationale:
1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues.
2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately.
3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support.
Summary:
A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system.
C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort.
D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.