Which of the following clients does the nurse identify as be...

Which of the following clients does the nurse identify as being at high risk for developing colorectal cancer? Select all that apply.

A. Client who has a diet high in red meat and low in fiber
B. Client who is morbidly obese
C. Client with a 15-year history of ulcerative colitis
D. Client with a 40-year history of cigarette smoking
E. Client with a family history of colorectal cancer

Correct Answer: A, C, E

Rationale: High red meat/low fiber diet (A), ulcerative colitis (C), and family history (E) are established risk factors for colorectal cancer. Obesity (B) and smoking (D) have weaker associations.

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Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.

A. Dimming the lights at night
B. Leaving the television on for diversion at night
C. Opening the window blinds/shades in the morning
D. Scheduling interventions and activities during the day when possible
E. Turning off equipment alarms in the client's room at night

Correct Answer: A, C, D

Rationale: Dimming lights (A), opening blinds in the morning (C), and scheduling activities during the day (D) promote circadian rhythms and rest. Leaving the TV on (B) may disrupt sleep, and turning off alarms (E) compromises safety.

In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?

A. White patches
B. Green drainage
C. Reddened tissue
D. Eschar development

Correct Answer: C

Rationale: Reddened tissue. Redness indicates granulation tissue formation, a sign of healing.

A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?

A. Touching the abdomen could cause cancer cells to spread.'
B. Examining the area would cause difficulty to the child.'
C. Pushing on the stomach might lead to the spread of infection.'
D. Placing any pressure on the abdomen may cause an abnormal experience.'

Correct Answer: A

Rationale: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.

Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?

A. I know there is a problem since my baby is always constipated.
B. My child doesn't like many fruits and vegetables, but she really loves her milk.
C. My child is not eating as much as she did 4 months ago.
D. My child doesn't drink a whole glass of juice or water at 1 time.

Correct Answer: B

Rationale: My child doesn't like many fruits and vegetables, but she really loves her milk. Excessive milk intake can displace iron-rich foods, leading to iron deficiency anemia.

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply.

A. Guide the client to the floor and gently cradle the head
B. Insert a tongue blade to prevent client from swallowing the tongue
C. Move objects that may cause injury away from the client
D. Physically restrain the client to prevent injury
E. Place the client in left lateral position
F. Remain with the client, observe, and record the seizure activity

Correct Answer: A, C, E, F

Rationale: Guiding to the floor (A), clearing objects (C), positioning laterally (E), and observing (F) ensure safety. Tongue blades (B) are dangerous, and restraining (D) increases injury risk.