The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patients plan of care?

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Question 1 of 9

The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patients plan of care?

Correct Answer: C

Rationale: The correct answer is C: Encourage the patient to keep his or her feeding area clean. This is the most appropriate independent nursing action as it promotes hygiene and reduces the risk of infection. Keeping the feeding area clean is essential in preventing complications in a patient with malnutrition. Rationales for why the other choices are incorrect: A: Firmly redirect the patient's head when feeding - This is incorrect because forceful redirection can cause distress and discomfort to the patient, potentially leading to aspiration or choking. B: Administer phenothiazines after each meal as ordered - This is incorrect as phenothiazines are not typically used for malnutrition treatment and should not be administered without a specific indication. D: Apply deep, gentle pressure around the patient's mouth to aid swallowing - This is incorrect because applying pressure around the mouth can pose a choking hazard and should not be done without proper assessment and intervention by a speech therapist or swallowing specialist.

Question 2 of 9

The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?

Correct Answer: A

Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely

Question 3 of 9

A nurse is assessing the health care disparitiesamong population groups. Which area is the nurse monitoring?

Correct Answer: A

Rationale: The correct answer is A: Accessibility of health care services. The nurse is monitoring disparities in access to healthcare services among different population groups. This is important as it can influence health outcomes and the prevalence of complications. Outcomes of health conditions (B) are impacted by access to care. Prevalence of complications (C) and incidence of diseases (D) can also be influenced by disparities in accessing healthcare services. However, the primary focus of the nurse's assessment in this scenario is on the accessibility of healthcare services as a key factor contributing to health care disparities.

Question 4 of 9

An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinsons disease. Which of the wifes descriptions of her husbands health and function is most suggestive of Parkinsons disease?

Correct Answer: A

Rationale: The correct answer is A because one of the hallmark symptoms of Parkinson's disease is bradykinesia, which is characterized by slowness of movement. This symptom commonly presents as a person moving far more slowly than usual. Option B is more indicative of arthritis or another musculoskeletal condition. Option C suggests possible cognitive decline or dementia, not specific to Parkinson's disease. Option D could indicate a different medical condition causing weight loss despite a good appetite. Therefore, A is the most suggestive of Parkinson's disease based on the symptom of bradykinesia.

Question 5 of 9

The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction?

Correct Answer: A

Rationale: The correct answer is A: Anaphylactic reaction after a bee sting. Type I hypersensitivity reactions involve an immediate response triggered by exposure to an allergen, leading to the release of histamine and other inflammatory mediators. In this case, a bee sting would introduce an allergen, causing a rapid and severe systemic reaction, known as anaphylaxis. B: Skin reaction resulting from adhesive tape is an example of a Type IV hypersensitivity reaction, mediated by T cells, not IgE antibodies as in Type I reactions. C: Myasthenia gravis is an autoimmune disorder involving antibodies attacking acetylcholine receptors, not a Type I hypersensitivity reaction. D: Rheumatoid arthritis is an autoimmune disorder involving immune complexes and inflammatory responses, not a Type I hypersensitivity reaction.

Question 6 of 9

A patient has experienced occasional urinary incontinence in the weeks since his prostatectomy. In order to promote continence, the nurse should encourage which of the following?

Correct Answer: A

Rationale: The correct answer is A: Pelvic floor exercises. Pelvic floor exercises help strengthen the muscles that control urination, promoting continence. These exercises can improve bladder control and reduce urinary incontinence post-prostatectomy. Intermittent urinary catheterization (B) may lead to increased risk of infection. Reduced physical activity (C) can weaken pelvic floor muscles, worsening incontinence. Active range of motion exercises (D) do not directly address urinary incontinence.

Question 7 of 9

A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin?

Correct Answer: D

Rationale: The correct answer is D: Immunoglobulin E. The atopic response in allergies is mainly mediated by IgE antibodies. IgE binds to allergens and triggers the release of histamine and other chemicals that cause allergic symptoms. IgA is mainly found in mucosal areas, IgM is involved in early immune responses, and IgG is important for long-term immunity. IgE is specifically associated with allergic reactions due to its role in sensitizing mast cells and basophils to allergens.

Question 8 of 9

In providing diabetic teaching for a patient with type 1 diabetes mellitus, which instructions will the nurse provide to the patient?

Correct Answer: B

Rationale: The correct answer is B: Saturated fat should be limited to less than 7% of total calories. This is because limiting saturated fat intake is crucial in managing type 1 diabetes to reduce the risk of cardiovascular diseases. Saturated fats can worsen insulin resistance and lead to complications. Choice A is incorrect as diabetic management involves more than just insulin. Choice C is incorrect because nonnutritive sweeteners should be used in moderation due to potential side effects. Choice D is incorrect as individuals with diabetes should aim to keep cholesterol intake low to prevent heart problems.

Question 9 of 9

A patient with ovarian cancer is admitted to the hospital for surgery and the nurse is completing the patients health history. What clinical manifestation would the nurse expect to assess?

Correct Answer: B

Rationale: The correct answer is B: Increased abdominal girth. In ovarian cancer, a common clinical manifestation is the accumulation of fluid in the abdomen, leading to increased abdominal girth. This is known as ascites. The presence of ascites can be observed through physical examination and abdominal imaging. A: Fish-like vaginal odor is not typically associated with ovarian cancer. It may be a symptom of other gynecological conditions. C: Fever and chills are not specific to ovarian cancer and can be seen in various infectious or inflammatory conditions. D: Lower abdominal pelvic pain is a common symptom in many gynecological conditions but is not a specific manifestation of ovarian cancer.

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