Nokea
The nurse is performing discharge teaching on a client at high risk for the development of skin cancer. Which instruction should be included in the client teaching?
- A. "You should see the doctor every six months."
- B. "Sunbathing should be done between the hours of noon and 3 p.m."
- C. "If you have a mole, it should be removed and biopsied."
- D. "You should wear sunscreen when going outside."
Correct Answer: D
Rationale: Wearing sunscreen protects against UV radiation, a key skin cancer risk factor. Regular checkups (A) are less specific, sunbathing at peak hours (B) increases risk, and routine mole removal (C) is excessive.
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The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:
- A. The tail of the pancreas
- B. The head of the pancreas
- C. The body of the pancreas
- D. The entire pancreas
Correct Answer: B
Rationale: The Whipple procedure (pancreaticoduodenectomy) is performed for cancer in the head of the pancreas, removing the head, duodenum, and other structures. Tail or body cancers require different surgeries.
The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?
- A. Pain, coolness, and blue discoloration in the affected joint
- B. Tingling and pain without loss of movement in the affected joint
- C. Warmth, redness, and decreased movement in the affected joint
- D. Stiffness, aching, and decreased movement in the affected joint
Correct Answer: D
Rationale: Hemarthrosis in hemophilia involves bleeding into joints, causing stiffness, aching, and decreased movement due to joint swelling and pain.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.
A client has been diagnosed with thrombophlebitis. She asks, 'What is the most likely cause of thrombophlebitis during my pregnancy?' The nurse explains:
- A. Increased levels of the coagulation factors and a decrease in fibrinolysis
- B. An inadequate production of platelets
- C. An inadequate intake of folic acid during pregnancy
- D. An increase in fibrinolysis and a decrease in coagulation factors
Correct Answer: A
Rationale: During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin.
When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
- A. Be direct, honest, and attentive.
- B. Approach them in the emergency room as soon as you suspect abuse to 'clear the air' right away.
- C. Ask the parents what they could have done differently to prevent this from happening to the child.
- D. After the interview, call child protective services.
Correct Answer: A
Rationale: The nurse must be honest, direct, professional, and attentive in her interview to gain the parent's trust. The nurse should approach the parents in private, away from the child. Asking them to relive and evaluate the situation may be looked at as placing blame on the parents for the child's 'accident.' At this point, the parents may get defensive and stop communicating. Although you may call child protective services, the nurse should inform the parents of their responsibility to do this and explain the process to them.