Nokea
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?
- A. White, cottage cheese-like patches on the
- B. Red, open sores on the oral mucosa
- C. Rust-colored sputum
- D. Yellow tooth discoloration
Correct Answer: B
Rationale: The correct answer is B because red, open sores on the oral mucosa are a common sign of stomatitis, which can be caused by chemotherapy. Stomatitis is characterized by inflammation and ulceration of the mouth lining. The other choices are incorrect because:
A: White, cottage cheese-like patches are indicative of oral thrush, a fungal infection.
C: Rust-colored sputum may indicate a respiratory condition or infection, not stomatitis.
D: Yellow tooth discoloration is not typically associated with stomatitis, but can be caused by various factors such as poor oral hygiene or certain foods.
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Which of the ff is a reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy?
- A. The adverse effect of mastectomy are immediate
- B. The wound of the surgery is highly contagious and the client should exercise isolation precautions immediately after the procedure
- C. Most clients are not hospitalized long after a mastectomy
- D. The suicidal tendencies in the women undergoing a mastectomy are high
Correct Answer: C
Rationale: Step 1: Most clients are not hospitalized long after a mastectomy - Correct. This is because mastectomy is often performed as an outpatient procedure, and clients are discharged home shortly after surgery.
Step 2: The adverse effects of mastectomy are not immediate - Incorrect. Adverse effects may occur post-surgery, but early discharge is not solely due to immediate adverse effects.
Step 3: The wound of the surgery is not highly contagious - Incorrect. Mastectomy wounds are not contagious, and isolation precautions are not necessary.
Step 4: Suicidal tendencies in women undergoing mastectomy are not high - Incorrect. While emotional support is crucial, early discharge is not primarily due to suicidal tendencies.
Summary: Choice C is correct because mastectomy clients are typically not hospitalized long, making early discharge instructions and home care arrangements necessary. Choices A, B, and D are incorrect as they do not directly relate to the primary reason for early discharge and home care planning.
A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?
- A. To restore and maintain intravascular volume
- B. To provide a means for further comparison and evaluation
- C. To avoid interference with wound drainage
- D. To prevent pain related to obstruction
Correct Answer: B
Rationale: The correct answer is B: To provide a means for further comparison and evaluation. By recording the color of drainage from each tube and catheter, the nurse can monitor changes over time, assess for any abnormalities, and evaluate the effectiveness of treatment. This helps in detecting complications early and making informed decisions.
Rationale for other choices:
A: To restore and maintain intravascular volume - Monitoring drainage color does not directly relate to intravascular volume status.
C: To avoid interference with wound drainage - Monitoring drainage color does not prevent interference with wound drainage.
D: To prevent pain related to obstruction - Monitoring drainage color does not directly prevent pain related to obstruction.
Aling Maria, a 58-year old female, was admitted for the third time because of myxedema. Initial assessment by Nurse Mida should include symptoms of:
- A. bradycardia, weight loss, heart failure, diarrhea
- B. tachycardia, constipation, exopthalmus
- C. lethargy, weight gain, slow speech, decreased RR
- D. hypothermia, weight loss, increased RR
Correct Answer: C
Rationale: The correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.
When evaluating the effectiveness of nursing interventions for sinusitis discomfort, which of the following does the nurse assess?
- A. WBC count
- B. Capillary refill
- C. Amount and color of sinus drainage
- D. Comfort level
Correct Answer: C
Rationale: The correct answer is C: Amount and color of sinus drainage. Assessing the amount and color of sinus drainage is crucial in evaluating the effectiveness of nursing interventions for sinusitis discomfort as it indicates the presence of infection or inflammation. Changes in color or amount can signify improvement or worsening of the condition. WBC count (A) may indicate infection but doesn't directly reflect sinusitis discomfort. Capillary refill (B) assesses circulation, not sinusitis. Comfort level (D) is subjective and can vary among individuals, making it less reliable for assessing the effectiveness of interventions.
Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
- A. Frontal lobe
- B. Six cranial nerve (abducent)
- C. Occipital lobe
- D. Eight Cranial Nerve (Vestibulocochlear)
Correct Answer: D
Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). Mr. Reyea's complaint of hearing ringing noises indicates a potential issue with his auditory function, which is primarily governed by the Vestibulocochlear nerve. This nerve is responsible for transmitting sound and balance information from the inner ear to the brain. The other choices, A: Frontal lobe, B: Six cranial nerve (abducent), and C: Occipital lobe, are not directly associated with auditory function or the perception of ringing noises in the ear.