adult health 1 ati quiz- week 3

A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching? A. "All recently used clothing, bedding, and towels must be washed in hot water." B. "My child must be free from nits before returning to school." C. "I will treat all the family members to be on the safe side." D. "Toys that can't be dry cleaned or washed must be thrown out."

A. "All recently used clothing, bedding, and towels must be washed in hot water." Rationale: Pediculosis capitis is commonly referred to as head lice. All recently used clothing, bed sheets, and towels need to be washed in hot water. Anything that cannot be washed should be sealed in a plastic bag for 10 to 14 days. Unwashable items can include jackets, sweaters, hats, pillows, bicycle helmets, and stuffed animals. Furniture, carpets, and car seats can be sprayed with a variety of over-the-counter products.

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. "I will clean the hearing aids with alcohol wipes." B. "I will not use hairspray if I am wearing the hearing aids." C. "I will change the batteries once a week." D. "I will expect the hearing aids to whistle when I cup my hand over them."

A. "I will clean the hearing aids with alcohol wipes." Rationale: Alcohol use can break down the mechanism of the hearing aids. The client should follow the manufacturer's instructions, which usually include using a soft cloth to remove cerumen and other debris and never immersing them in water.

A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? A. "The teacher says my child has to squint to see the board." B. "My child has recently lost both front top teeth." C. "My child often cheats when we play board games." D. "Sometimes my child acts bossy with his friends."

A. "The teacher says my child has to squint to see the board." Rationale: Squinting to see the board can indicate a vision problem. It is essential to assess children for hearing and vision problems. If not caught early, they lead to frustration and decreased ability to learn

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. B. Irrigate the wound with an antiseptic prior to obtaining the specimen. C. Include intact skin at the wound edges in the culture. D. Swab an area of skin away from the wound to identify the usual flora.

A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. Rationale: The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? A. Do not apply heat to the area of irradiation. B. Do not wash the area of irradiation. C. Use an antibiotic ointment to treat skin breakdown. D. Lubricate the skin lubricated with hypoallergenic lotion.

A. Do not apply heat to the area of irradiation. Rationale: This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to a potential burn injury. When outdoors in sunlight, the client should wear protective clothing over the area of irradiation

A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine? A. "Administer the medication with food." B. "Chew on sugarless gum or suck on hard, sour candies." C. "Place a humidifier at your bedside every evening." D. "Discontinue the medication and notify your provider."

B. "Chew on sugarless gum or suck on hard, sour candies." Rationale: Clients who report dry mouth can get the most effective relief by sucking on hard candies (especially the sour varieties that stimulate salivation), chewing gum, or rinsing the mouth frequently. It is the local effect of these actions that provides comfort to the client.

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider? A. "My eye really itches, but I'm trying not to rub it." B. "I need something for the pain in my eye. I can't stand it." C. "It's hard to see with a patch on one eye. I'm afraid of falling." D. "The bright light in this room is really bothering me."

B. "I need something for the pain in my eye. I can't stand it." Rationale: Following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage

A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include? A. "Rest in bed for at least 2 days." B. "Keep your head up and straight." C. "Deep breathe and cough four times a day." D. "Lie on the side of the surgery when in bed."

B. "Keep your head up and straight." Rationale: Keeping the head straight and avoiding looking down prevents increasing intraocular pressure.

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer? A. Squamous cell carcinoma B. Basal cell carcinoma C. Malignant melanoma D. Actinic keratosis

B. Basal cell carcinoma Rationale: A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent, pearly borders. Telangiectatic vessels can also be present. As a basal cell tumor grows, it can undergo central ulceration.

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? A. Electrical cords are placed along the walls. B. Scatter rugs are present in the kitchen. C. Handrails are present in the bathroom. D. Uses a microwave for cooking. Created

B. Scatter rugs are present in the kitchen. Rationale: Scatter rugs in the kitchen are a safety hazard. The client could trip on one of the rugs and fall due to impaired vision.

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)? A. Admission assessment of a new client B. Scheduling a diagnostic study for a client C. Evaluating changes to a client's pressure ulcer D. Teaching a client insulin injection technique

B. Scheduling a diagnostic study for a client Rationale: The LPN can schedule a diagnostic study as this does not involve assessment or nursing

A nurse is caring for a client who is postpartum. Th e client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? A. "There is no need to worry about that. Most forms of hearing loss are not inherited." B. "Look at how she looks as you when you speak. That's a good sign." C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."

C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." Rationale: Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss, but determine whether or not a newborn requires further evaluation.

A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating? A. Assign an assistive personnel to feed the client. B. Explain to the client that her tray is here and place her hands on it. C. Describe to the client the location of the food on the tray. D. Ask the client if she would prefer a liquid diet.

C. Describe to the client the location of the food on the tray.

A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan? A. Enforce strict bedrest for 3 days. B. Apply fresh ice packs every 4 hr. C. Elevate the affected leg on two pillows. D. Apply antibiotic ointment to the wound with dressing changes.

C. Elevate the affected leg on two pillows. Rationale: Cellulitis is an acute inflammation of the deep connective tissue of the skin, caused by infection, The edema of the inflammatory response puts the client at risk for skin breakdown.. Elevation of the affected area and frequent repositioning reduces dependent edema and assists in the healing process.

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Blood pressure 102/66 mm Hg B. Straw-colored urine from an indwelling urinary catheter C. Yellow-green drainage on the surgical incision D. Respiratory rate 18/min

C. Yellow-green drainage on the surgical incision Rationale: Thick yellow-green drainage is indicative of an infection and should be reported immediately

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? A. Speak using his usual tone of voice. B. Stand directly in front of the client. C. Rephrase statements the client does not hear. D. Determine if the client uses hearing aids.

D. Determine if the client uses hearing aids.

A nurse is providing teaching to a 17-year-old female client who has severe acne about the use of isotretinoin. Which of the following adverse effects should the nurse instruct the client is the priority to report to the provider? A. Frequent nosebleeds B. Itching of skin C. Back pain D. Feelings of isolation

D. Feelings of isolation Rationale: Feelings of isolation can indicate suicide ideation, which can lead to self-harm. Therefore, this adverse effect is the priority to report to the provider.