The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?

Correct Answer: B

Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke. Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia. Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them. Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.

Correct Answer: D

Rationale: The correct answer is 'Ocular movements.' Moving the eyes through the six cardinal fields of gaze evaluates the function of the eye muscles, such as the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Normal movement in these fields indicates proper ocular movements. Near vision is assessed using a handheld vision screener, central vision with a Snellen chart, and peripheral vision through the confrontation test. Therefore, the evaluation of ocular movements through the six cardinal fields of gaze specifically assesses this aspect of eye function. Choices A, B, and C are incorrect as they pertain to different aspects of vision function that are evaluated using distinct assessment methods, not through the six cardinal fields of gaze.

Correct Answer: D

Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.

Correct Answer: D

Rationale: The correct answer is, 'I take my Lipitor and my other morning medications with my grapefruit juice at breakfast.' This statement indicates a need for reinforced teaching because grapefruit juice should be avoided when taking Lipitor. Grapefruit juice blocks the enzymes needed to break down the drug, which leads to excessive amounts of the drug in the body. Choices A, B, and C show appropriate timing and administration of Lipitor, whereas choice D poses a potential risk due to the interaction between grapefruit juice and Lipitor.

Correct Answer: B

Rationale: The correct answer is Osteoarthritis. Osteoarthritis is characterized by hard, nontender nodules of 2 to 3 mm or larger. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes. In this disorder, when these nodes occur on the proximal interphalangeal joints, they are called Bouchard nodes. Heberden nodes are not associated with scoliosis, rotator cuff lesions, or carpal tunnel syndrome. Therefore, choices A, C, and D are incorrect.

Correct Answer: C

Rationale: In the Rinne test, the base of an activated tuning fork is held first against the mastoid bone, behind the ear, and then in front of the ear canal (0.5 to 2 inches). When the client no longer perceives the sound behind the ear, the fork is moved in front of the ear canal until the client indicates that the sound can no longer be heard. The client reports whether the sound from the tuning fork is louder behind the ear (on the mastoid bone) or in front of the ear canal. Placing the tuning fork on the teeth (Choice A), forehead (Choice B), or the midline of the skull (Choice D) is not part of the Rinne test procedure. Therefore, the correct answer is to first place the activated tuning fork on the client's mastoid bone.

Correct Answer: D

Rationale: The nurse performs the Allen test to determine the patency of the radial and ulnar arteries. During the test, the nurse applies pressure over the client's ulnar and radial arteries simultaneously. The client is then asked to open and close the hand repeatedly, causing the hand to blanch. Subsequently, the nurse releases pressure from the ulnar artery while compressing the radial artery and checks the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, it indicates that the ulnar artery is insufficient, suggesting that the radial artery should not be used for obtaining a blood specimen. Choice A (Capillaries) is incorrect as the Allen test assesses the patency of larger arteries, not capillaries. Choice B (Pedal pulses) is incorrect as the Allen test specifically evaluates the radial and ulnar arteries, not the pedal pulses in the foot. Choice C (Femoral arteries) is incorrect as the Allen test focuses on the radial and ulnar arteries in the hand, not the femoral arteries in the leg.

Correct Answer: D

Rationale: The correct answer is Fluoxetine. Among the options provided, Fluoxetine is the medication least likely to cause tinnitus. Gentamicin, Lasix, and Aspirin are known ototoxic medications that have a potential side effect of causing tinnitus, a ringing in the ear. Gentamicin is an antibiotic, Lasix is a diuretic, and Aspirin is a common pain reliever that can lead to tinnitus. In contrast, Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) primarily used as an antidepressant, and it has a lower risk of causing tinnitus compared to the other options.

Correct Answer: A

Rationale: The correct term for generalized edema over the entire body is 'Anasarca.' Anasarca is indicative of a systemic issue such as congestive heart failure or kidney failure. It does not refer to increased vascularity of the skin tissue. Ecchymosis is a bruise caused by capillary bleeding into the tissues, unrelated to generalized edema. Unilateral edema is swelling in a specific area of the body, not the generalized edema observed in anasarca.