Nokea
The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?
- A. McGill Pain Scale
- B. FLACC Pain Scale
- C. CRIES Pain Scale
- D. Wong-Baker Pain Scale
Correct Answer: D
Rationale: The correct answer is the Wong-Baker Pain Scale. This scale is specifically designed for pediatric clients, including children as young as 3 years old, making it the most appropriate choice for a 4-year-old. It utilizes a simple visual scale with facial expressions that children can easily understand and use to express their pain levels. The FLACC and CRIES Pain Scales are also used for pediatric clients but are more focused on non-verbal cues and specific populations like infants or critically ill children. The McGill Pain Scale, on the other hand, is more complex and uses descriptive words, making it more suitable for adult clients who can better articulate their pain experiences.
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An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?
- A. Loud music
- B. Use of power tools
- C. Occupational noise
- D. Exposure to cigarette smoke
Correct Answer: D
Rationale: The correct answer is 'Exposure to cigarette smoke.' Otitis media (middle ear infection) is associated with various factors like colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include exposure to cigarette smoke, youth (as otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, family history of otitis media, recent upper respiratory infections, and allergies. Choices A, B, and C (Loud music, Use of power tools, and Occupational noise) are more likely to cause hearing loss rather than being direct risk factors for middle ear infections.
A nurse is reviewing a patient's current Lithium levels. Which of the following values is outside the therapeutic range?
- A. 1.0 mEq/L
- B. 1.1 mEq/L
- C. 1.2 mEq/L
- D. 1.3 mEq/L
Correct Answer: D
Rationale: 1.0-1.2 mEq/L is considered standard therapeutic range for patient care.
The LPN is caring for a client taking Lipitor (Atorvastatin). Which of these statements would indicate that the client may need reinforced teaching?
- A. "I take my Lipitor with a glass of milk after my breakfast."?
- B. "I take my Lipitor and wait 30 minutes before taking my other medications."?
- C. "I take my Lipitor 30 minutes after I eat something."?
- D. "I take my Lipitor and my other morning medications with my grapefruit juice at breakfast."?
Correct Answer: D
Rationale: The correct answer is, 'I take my Lipitor and my other morning medications with my grapefruit juice at breakfast.' This statement indicates a need for reinforced teaching because grapefruit juice should be avoided when taking Lipitor. Grapefruit juice blocks the enzymes needed to break down the drug, which leads to excessive amounts of the drug in the body. Choices A, B, and C show appropriate timing and administration of Lipitor, whereas choice D poses a potential risk due to the interaction between grapefruit juice and Lipitor.
Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?
- A. "I should put alcohol on my baby's cord 3-4 times a day."?
- B. "I should put the baby's diaper on so that it covers the cord."?
- C. "I should call the physician if the cord becomes dark."?
- D. "I should wash my hands before and after I take care of the cord."?
Correct Answer: A
Rationale: Explanation: Parents should be taught that putting alcohol or other antimicrobials on the cord is no longer recommended for cord care. This can interfere with the natural healing process and may increase the risk of irritation or infection. Washing hands before and after providing cord care is essential to prevent the transfer of pathogens. Placing the baby's diaper below the cord allows it to be exposed to air and promotes drying, reducing the risk of infection. It is normal for the cord to turn dark as it dries, so calling the physician only if the cord becomes red, swollen, or has discharge is appropriate. Therefore, the statement '"I should put alcohol on my baby's cord 3-4 times a day."?' indicates a need for further teaching about cord care.
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.