While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

The immunization schedule recommended for the client's age.

The need for regular mammogram screening to identify breast cancer lesions.

The need for consistent use of seat belts when in a motor vehicle.

The impact of annual vision examinations on personal health and safety.

Answer and Explanation

The Correct Answer is B

Choice a reason:
Immunization schedules are typically considered a part of primary prevention. They are intended to prevent diseases before they occur by using vaccines to provide immunity against infections.

Choice b reason:
Regular mammogram screenings are a form of secondary prevention. They are used to detect breast cancer lesions early before symptoms appear, which can lead to more effective treatment and better outcomes.

Choice c reason:
The consistent use of seat belts is a primary prevention strategy. It is a proactive measure to prevent injuries in the event of a motor vehicle accident.

Choice d reason:
Annual vision examinations can be considered part of secondary prevention if they are used to detect vision problems or eye diseases in their early stages. However, they can also be seen as primary prevention because they help maintain and protect eye health before issues arise.

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Correct Answer is D

Explanation

Choice A Reason:
Looking down does not typically expose the sclera and conjunctiva for examination. The lower eyelid covers more of the sclera when the eyes are directed downward, making it less accessible for observation.

Choice B Reason:
Moving the eyes to the left is not the standard direction for examining the sclera and conjunctiva. This movement would not provide an optimal view of the entire sclera and conjunctiva, as it would only stretch the lateral part of the conjunctiva.

Choice C Reason:
Directing the eyes to the right, similar to moving them to the left, does not offer the best exposure for examining the sclera and conjunctiva. The medial part of the conjunctiva would be stretched, but the rest would not be easily visible.

Choice D Reason:
Instructing the client to look up is the correct procedure when examining the sclera and conjunctiva. By looking upward, the client exposes more of the sclera and the palpebral conjunctiva, allowing the nurse to inspect these areas thoroughly for any abnormalities such as redness, swelling, or foreign bodies.

A. Refer the client for medical follow-up. B. Ask the client about a family history of cancer. C. Document the benign findings. D. Perform a random blood sugar test.

Correct Answer is A

Explanation

Choice a reason :
Referring the client for medical follow-up is the most appropriate action. Acanthosis Nigricans is often associated with insulin resistance and is a risk factor for diabetes mellitus. The client's symptoms of fatigue, thirst, and frequent urination are classic signs of diabetes. Therefore, a comprehensive medical evaluation is necessary to rule out diabetes or other underlying conditions that could be causing these symptoms.
Choice b reason
While Acanthosis Nigricans can sometimes be associated with malignancy, it is more commonly linked to insulin resistance and diabetes. The client's presenting symptoms are not typical of cancer but are indicative of diabetes. Therefore, while a family history of cancer is relevant to the client's overall health, it is not the immediate concern based on the current presentation.
Choice c reason
Documenting findings is an essential part of the nursing process; however, the presence of Acanthosis Nigricans, especially when coupled with symptoms of fatigue, thirst, and frequent urination, should not be considered benign without further investigation. These findings warrant further assessment to determine the underlying cause.
Choice d reason
Performing a random blood sugar test could be a part of the initial assessment; however, it should not replace a referral for a comprehensive medical evaluation. A random blood sugar test alone may not be sufficient to diagnose diabetes or determine the cause of the client's symptoms. A full medical follow-up will likely include blood sugar testing along with other diagnostic tests.

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While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

Correct Answer is D

Explanation

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae (Acanthosis Nigricans). What would the nurse do next?

Correct Answer is A

Explanation

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