The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

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Question 1 of 5

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

Correct Answer: A

Rationale: Jaundice, if present, can be best assessed in areas such as the sclera, nail beds, and mucous membranes due to the yellowing of these tissues. The nail beds specifically provide a good indication of jaundice. The skin in the sacral area (Option B) is not typically the best area for assessing jaundice as it is less visible and not as reliable as the nail beds. The skin in the abdominal area (Option C) may show generalized jaundice, but the nail beds are more specific for detecting early signs. Lastly, assessing the membranes in the ear canal (Option D) is not a standard method for evaluating jaundice; the sclera and nail beds are more commonly used for this purpose.

Question 2 of 5

A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition?

Correct Answer: C

Rationale: A client with a severe vitamin C deficiency has a condition called scurvy. Scurvy is characterized by symptoms such as bleeding gums, loose teeth, poor wound healing, and easy bruising. The correct answer is 'Bleeding gums and loose teeth' because these are classic signs of scurvy due to vitamin C deficiency. Choice A ('Cracks at the corners of the mouth') is more indicative of a deficiency in B vitamins, specifically riboflavin. Choice B ('Altered mental status') is not typically associated with vitamin C deficiency but can occur with other conditions like vitamin B12 deficiency. Choice D ('Anorexia and diarrhea') are not common symptoms of vitamin C deficiency, as they are more commonly associated with other gastrointestinal issues or deficiencies in different nutrients.

Question 3 of 5

A client using an intraaural hearing aid experiences whistling after placement. What is the nurse's next action?

Correct Answer: A

Rationale: An intraaural hearing aid, also known as an in-the-ear hearing aid, is placed in the ear canal. Whistling after placement indicates improper positioning of the device. The correct action for the nurse is to try repositioning the hearing aid to eliminate the whistling. Changing the batteries is not necessary for addressing whistling. Removing the device to clean it is not the immediate action needed for whistling. Notifying the physician is premature without attempting to reposition the hearing aid first.

Question 4 of 5

The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?

Correct Answer: A

Rationale: The correct answer is chronic vessel plaque formation. Kawasaki Disease affects small and medium-sized blood vessels, leading to progressive inflammation and potential damage to the walls of medium-sized muscular arteries, which can result in coronary artery aneurysms. While other complications such as pulmonary embolism and occlusions at vessel bifurcations can occur in different conditions, for Kawasaki Disease, the primary concern is the development of chronic vessel plaque formation.

Question 5 of 5

A healthcare professional has just received a medication order that is not legible. Which statement best reflects assertive communication?

Correct Answer: B

Rationale: Assertive communication respects the rights and responsibilities of both parties. Choice B is the best example of assertive communication in this scenario. It addresses the issue directly by requesting clarification without blaming or devaluing the prescriber. This approach shows concern for safe practice and acknowledges the importance of clear communication in healthcare. Choices A, C, and D either involve self-depreciation, blaming the prescriber, or making demands without a respectful request for clarification, making them less effective in promoting effective communication and safe patient care.

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