Nokea
Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?
- A. Keep eyes closed
- B. Wear sunglasses
- C. Do not drive for 8 hours
- D. Avoid caffeinated beverages
Correct Answer: B
Rationale: The correct answer is B: Wear sunglasses. Dilated pupils are sensitive to light, so wearing sunglasses can help protect the eyes from excessive light exposure. Keeping the eyes closed (A) may provide temporary relief but does not protect the eyes from light. Avoiding driving for 8 hours (C) is important after certain eye procedures but not specifically related to dilated pupils. Avoiding caffeinated beverages (D) is unrelated to pupil dilation.
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Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
- A. I’ll be flying overseas to see my son and grandchildren for the holidays
- B. I plan to do my leg exercises at least three times a week
- C. I’m going to be walking in the mall everyday to build up my strength
- D. At night when I sleep, I like to use two pillows to raise my head up CARING FOR CLIENTS FOR DISORDERS OF THE LYMPHATIC SYSTEM
Correct Answer: D
Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale:
1. Asking about chief concerns helps to focus the interview on the patient's needs.
2. It demonstrates active listening and empathy.
3. Allows the nurse to prioritize issues and provide appropriate care.
4. Introductions are already done, and ending the interview abruptly or mentioning medication timing is not patient-centered.
Which of the ff finding would confirm that a female client has mastitis? Choose all that apply
- A. A crack in the nipple or the areola
- B. Multiple lumps within the breast tissue
- C. Swollen, firm, and hard breasts
- D. Enlargement of the axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C because mastitis typically presents with swollen, firm, and hard breasts due to inflammation and infection of the breast tissue. This occurs as a result of milk stasis and bacterial infection. Option A is incorrect because a crack in the nipple or areola can be indicative of nipple trauma or infection, not necessarily mastitis. Option B is incorrect because multiple lumps within the breast tissue may suggest fibrocystic changes or breast cancer, but not specifically mastitis. Option D is incorrect because enlargement of the axillary lymph nodes is more commonly seen in breast cancer, not mastitis.
At a public health fair, a nurse discusses the dangers of sun exposure. Prolonged sun exposure has been blamed for which form of cancer?
- A. Malignant melanoma
- B. Basal cell epithelioma
- C. Squamous cell carcinoma
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, "All of the above." Malignant melanoma, basal cell epithelioma, and squamous cell carcinoma are all types of skin cancer associated with prolonged sun exposure. Melanoma is the most dangerous form, while basal cell and squamous cell carcinomas are more common but less aggressive. Sun exposure can lead to DNA damage in skin cells, increasing the risk of developing these types of cancers. Therefore, all three choices are correct as they are all linked to sun exposure. The other choices are incorrect because each type of skin cancer mentioned can be caused by prolonged sun exposure, so selecting any one of them individually would not fully capture the scope of the risks associated with sun exposure.
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.