Nursing Elites

1. A client states, "I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?"? The nurse should respond with which of the following statements?

• A. Sleep at least 6-8 hours per night.
• B. Practice monthly self-breast examinations.
• C. Reduce stress.
• D. All of the above.

Correct answer: D

Rationale: All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. Stress can have a physiological response in the body that decreases the immune response and increases the risk of disease. Therefore, all the options provided are important in cancer prevention, making 'All of the above' the correct answer. Option A is crucial for overall health and immune function, option B aids in early detection, and option C is vital as chronic stress can weaken the immune system.

2. What causes an older female client's hair to turn gray?

• A. ''A loss of melanin occurs in the normal aging process.''
• B. ''The number of sweat glands and blood vessels decreases in the normal aging process.''
• C. ''The skin on the scalp becomes thin, causing moisture to escape.''
• D. ''It is caused by hereditary factors.''

Correct answer: A

Rationale: The correct answer is 'A loss of melanin occurs in the normal aging process.' Graying hair in older adults is primarily due to a decrease in the number of melanocytes responsible for providing pigment and hair color. This reduction in melanin production leads to gray hair. The other choices are incorrect. While it is true that the skin becomes thinner with aging and the number of sweat glands and blood vessels decreases, these changes are not directly related to graying hair. Additionally, hereditary factors can influence when graying starts, but they do not cause the graying of hair itself.

3. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?

• A. Trochlear nerve
• B. Abducens nerve
• C. Trigeminal nerve
• D. Oculomotor nerve

Correct answer: C

Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.

4. A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client?

• A. If your 2-year-old becomes angry or jealous, you should consider preparing the child for the new sibling rather than seeking psychological intervention.
• B. Don't worry; every 2-year-old may need time to adjust to a newborn sibling.
• C. Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.
• D. A 2-year-old toddler focuses on exploring the environment, but it's important to prepare the child for the new sibling.

Correct answer: C

Rationale: The correct response by the nurse is, 'Even though a 2-year-old may have little perception of time, any changes in sleeping arrangements for the newborn should be made several weeks before birth.' Toddlers are generally unaware of the changes during pregnancy and may not understand the impending arrival of a new sibling. It is essential to prepare the child gradually for the new baby's arrival by making any necessary changes in sleeping arrangements beforehand. Expecting a young child to immediately welcome a new sibling without prior preparation is unrealistic. Option A is incorrect as suggesting psychological intervention prematurely is not appropriate. Option B is incorrect as assuming all 2-year-olds would immediately welcome a newborn is unrealistic. Option D is incorrect as dismissing the concerns without addressing the need for preparation is not appropriate in this situation.

5. An LPN is reviewing medication lists for several clients recently admitted to the hospital. Which of the following scenarios would be least concerning?

• A. A client taking allopurinol for gout states they have been taking black cohosh to help with post-menopausal symptoms.
• B. A client has an order for warfarin and states they have been taking Ginkgo biloba to improve their memory.
• C. A client taking Lipitor states they have been taking ginseng for an energy boost.
• D. A client has a prescription for an SSRI and states they have been taking St. John's wort to also help with their depression.

Correct answer: C

Rationale: The least concerning scenario is when a client taking Lipitor states they have been taking ginseng for an energy boost. While ginseng may cause an increased risk of bleeding, it should not interact with Lipitor. On the other hand, St. John's wort should not be taken with an SSRI as it may cause serotonin syndrome, posing a more serious concern. Black cohosh should not be taken with allopurinol as they can both cause hepatotoxicity, especially in combination. Ginkgo biloba should not be taken with warfarin as it causes an increased risk of bleeding, making it a more concerning scenario compared to the client taking Lipitor and ginseng.

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