Nokea
The nurse is developing a program on skin cancer prevention for a community group. Which of the following should be included in the program? Select all that apply.
- A. Purchase sunscreen containing benzophenoness to check UVA and UVB rays.
- B. Use sunscreen with a minimum of 15 sun protection factor (SPF).
- C. Obtain genetic screening to identify risk of melanoma.
- D. Apply sunscreen only on sunny days, especially between 10 AM and 2 PM.
- E. Have a pigmented lesion biopsied by shaving if it looks suspicious.
- F. Rub baby oil to lubricate skin before going out in the sun.
Correct Answer: A,B
Rationale: Sunscreen with benzophenones and SPF 15 or higher protects against UVA/UVB rays. Genetic screening is not routine, sunscreen should be used daily, shave biopsies are inappropriate, and baby oil increases UV damage.
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A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit:
- A. Is a temporary procedure that can be reversed later.
- B. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
- C. Conveys urine from the ureters to a stoma opening on the abdomen.
- D. Creates an opening in the bladder that allows urine to drain into an external pouch.
Correct Answer: C
Rationale: An ileal conduit diverts urine from the ureters to an abdominal stoma, where it is collected in an external pouch, a permanent procedure for bladder cancer management.
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
- A. Fluid and gas have been removed from the intestine.
- B. The client has had a bowel movement.
- C. The client's urinary output is adequate.
- D. The client can sit up without pain.
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate
The client has midcalf pain when walking a block or more. The client states that the discomfort is relieved with rest. The pain is expected when arterial occlusion reaches which of the following percentages?
- A. 20%
- B. 40%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: Claudication typically occurs when arterial occlusion reaches approximately 50%, significantly reducing blood flow to muscles during activity. This causes ischemia and pain, which is relieved by rest when oxygen demand decreases. Complete (100%) occlusion would cause rest pain or tissue necrosis, not just claudication.
At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia?
- A. Early in the morning, when the client's energy level is high.
- B. To coincide with the peak action of drug therapy.
- C. Immediately after a rest period.
- D. When family members will be available.
Correct Answer: B
Rationale: Scheduling activities during peak drug action (e.g., levodopa) maximizes mobility and reduces hypokinesia. Morning energy, rest periods, or family availability are less directly tied to symptom control.
There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
- A. Cut around blood stains to remove clothing.
- B. Place each item of clothing in a separate paper bag.
- C. Allow clothing to dry.
- D. Refrain from documenting client statements.
- E. Place bullets in a sterile container.
Correct Answer: B
Rationale: To preserve forensic evidence, clothing should be placed in separate paper bags to prevent cross-contamination. Cutting around blood stains or placing bullets in sterile containers may damage evidence, and documentation of statements is necessary for legal purposes.