Question

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

Answer 1

Correct Answers:

“Eating a high fiber diet will reduce my risk for developing skin cancer.”.

Rationale :

🔹 Skin cancer is primarily caused by UV radiation exposure, not dietary fiber intake.

🔹 A high-fiber diet supports colon health but has no proven link to reducing skin cancer risk.

🔹 Preventive measures focus on sun protection, including the use of sunscreen, protective clothing, and limiting sun exposure.

🔹 Early detection via self-skin exams is key to improving outcomes.

🔹 Tanning booths emit UV-A and UV-B rays, which are carcinogenic and increase melanoma risk.

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Answer 2

Correct Answers:

Avoid foods prepared with tap water.

Rationale :

🟪 Hepatitis A and E can spread via contaminated food and water, especially in underdeveloped areas.

🟪 Clients at risk should avoid uncooked foods, unbottled water, and foods washed in tap water.

🟪 Practicing proper hand hygiene is crucial, not avoiding it.

🟪 Covering open sores prevents blood exposure, essential in Hep B and C transmission prevention.

🟪 Meat is not a common vector unless improperly cooked or handled.

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Answer 3

Correct Answers:

Palpate the area behind the ankle bone.
Use the pads of the fingers to feel for the pulse.
Compare the pulse strength with the other leg.
Assess for any swelling or tenderness

Rationale :

🟨 The posterior tibial pulse is located behind the medial malleolus (ankle bone).

🟨 Always use the pads of your index and middle fingers, not the thumb, for pulse detection.

🟨 Always compare bilaterally to assess for asymmetry in perfusion.

🟨 Swelling or tenderness could indicate vascular or musculoskeletal compromise.

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Answer 4

Correct Answers:

Headache is a common side effect of nitrates.

Rationale :

♦ Nitrates cause vasodilation, which often results in headaches due to cerebral vessel dilation.

♦ Acetaminophen is commonly co-prescribed to relieve or prevent nitrate-induced headaches.

♦ It does not interfere with platelet function, unlike aspirin, making it safer in bleeding risk.

♦ Headache is dose-related, and tolerance may develop over time.

♦ Teaching the patient about this common side effect enhances compliance.

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Answer 5

Correct Answers:

Slurred speech.

Rationale :

🟩 Slurred speech is a neurological symptom that could indicate a stroke or embolism, both urgent.

🟩 Clients with atrial fibrillation are at high risk for embolic stroke due to clot formation.

🟩 Fatigue and edema are expected symptoms in heart failure, not emergent.

🟩 Prompt recognition of stroke signs (e.g., FAST) can prevent permanent damage.

🟩 This finding requires immediate provider notification and likely neuroimaging.

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Answer 6

Correct Answers:

Spider angiomas.

Rationale :

🔷 Spider angiomas are vascular lesions often seen in chronic liver disease due to estrogen buildup.

🔷 Cirrhosis impairs liver detoxification, leading to hormonal imbalance and skin changes.

🔷 Other signs include jaundice, ascites, and palmar erythema.

🔷 Moist skin would be atypical; clients more often have dry, itchy skin.

🔷 GI bleeding, not tarry stools, is possible in portal hypertension but spider angiomas are more specific.

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Answer 7

Correct Answers:

A client who has diabetes mellitus.

Rationale :

🟧 Diabetes causes endothelial damage, leading to increased risk for atherosclerosis, the underlying cause of PAD.

🟧 Clients may develop intermittent claudication and reduced lower limb perfusion.

🟧 PAD risk is compounded by hyperglycemia, hypertension, and smoking.

🟧 Hypothyroidism does not have a direct link to PAD.

🟧 Caloric fat percentage is less predictive than metabolic diseases like diabetes.

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Answer 8

Correct Answers:

Weak pedal pulses.

Rationale :

🟪 Buck’s traction is used for immobilization; neurovascular compromise like weak pedal pulses signals vascular obstruction.

🟪 Complications can lead to compartment syndrome, a medical emergency.

🟪 Toes should remain warm with brisk cap refill; weak or absent pulses are abnormal.

🟪 Leg discomfort may be expected but pulses are more diagnostic.

🟪 Frequent neurovascular checks are mandatory for traction patients.

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Answer 9

Correct Answers:

Crackles, peripheral edema, and weight gain.

Rationale :

♦ These signs indicate fluid overload, a hallmark complication of heart failure, which is a major risk in infective endocarditis.

♦ Vegetations can impair valve function, leading to regurgitation and HF symptoms.

♦ Pulmonary crackles suggest left-sided heart failure; edema and weight gain point to right-sided involvement.

♦ Close monitoring of fluid status is essential in endocarditis cases.

♦ The nurse must report these findings to prevent decompensation.

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Answer 10

Correct Answers:

The weights rest against the foot of the bed.

Rationale :

🔹 Buck’s traction requires free-hanging weights to maintain proper countertraction.

🔹 Weights resting on the bed eliminate tension and make the traction ineffective.

🔹 This setup can lead to misalignment of bones and soft tissues.

🔹 It increases the risk for pressure injuries and neurovascular compromise.

🔹 Nurses must routinely check traction alignment and pulley setup.

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QLexNursing

1 :
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

2 :
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?

3 :
A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)

5 :
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

6 :
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

7 :
A nurse is providing teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?

8 :
The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

9 :
When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?

10 :
A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

QLexNursing

1 : A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

2 : A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?

3 : A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)

5 : A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

6 : A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

7 : A nurse is providing teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?

8 : The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

9 : When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?

10 : A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

1 :
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

2 :
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?

3 :
A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)

5 :
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

6 :
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

7 :
A nurse is providing teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?

8 :
The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

9 :
When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?

10 :
A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?