Nokea
Miss OB’s malignant tumor in her left breast was discovered to be spreading all over the surrounding and adjacent tissue and not entering the blood stream, it would be:
- A. Malignant
- B. Non-malignant
- C. Benign
- D. B and C
Correct Answer: A
Rationale: The correct answer is A: Malignant. A malignant tumor spreading to surrounding tissues indicates invasive growth, characteristic of malignancy. It is aggressive and can invade nearby structures. Non-malignant tumors are localized and do not invade surrounding tissues. Benign tumors are non-invasive and do not spread to other parts of the body. Choice D is incorrect because a tumor spreading to surrounding tissues is indicative of malignancy, not benignity.
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The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?
- A. Assisting with activities of daily living
- B. Counseling about respite care options
- C. Teaching range-of-motion exercises
- D. Consulting with a social worker
Correct Answer: B
Rationale: The correct answer is B: Counseling about respite care options. This intervention is most appropriate as it addresses the issue of role strain by providing the family member with support and options for temporary relief from caregiving responsibilities. Respite care allows the family member to take a break and recharge, reducing stress and preventing burnout.
A: Assisting with activities of daily living is important but may not directly address the underlying issue of role strain.
C: Teaching range-of-motion exercises is beneficial for physical well-being but does not directly address the emotional and psychological impact of role strain.
D: Consulting with a social worker may be helpful for additional support but may not provide immediate relief or practical solutions for the family member's role strain.
Which instruction about insulin administration should the nurse give to a client?
- A. “Always follow the same order when drawing the different insulin into the syringe.”
- B. “Shake the vial before withdrawing the insulin.”
- C. “Store unopened vials of insulin in the freezer at temperatures well below freezing.”
- D. “Discard the intermediate-acting insulin if it disappears cloudy.”
Correct Answer: A
Rationale: The correct answer is A because maintaining consistency in the order of drawing different types of insulin into the syringe helps prevent medication errors. When mixing insulins, drawing them in the same sequence ensures the correct dose and prevents contamination.
Explanation:
A: Following the same order ensures accurate dosing and minimizes the risk of mixing up insulins.
B: Shaking the vial can cause air bubbles which can affect the accuracy of the dose.
C: Storing insulin in the freezer can damage the medication and alter its effectiveness.
D: Cloudiness in intermediate-acting insulin is normal and does not indicate it should be discarded.
A 36-year-old man is scheduled for a unilateral orchiectomy for treatment of testicular cancer. He is withdrawn and does not interact with the nurse. Which action is most appropriate?
- A. Identify the problem with a nursing diagnosis of impaired communication related to the diagnosis of cancer
- B. Set a patient outcome that the patient will verbalize his concerns about his diagnosis
- C. Ask the patient whether he is worried about future sexual functioning
- D. Say, “You seem quiet. Are you feeling concerned about your diagnosis or treatment?”
Correct Answer: D
Rationale: Step-by-step rationale for choosing answer D as correct:
1. Acknowledges patient's withdrawn behavior
2. Demonstrates empathy and concern
3. Open-ended question allows patient to express feelings
4. Encourages patient to communicate concerns
Summary:
- Option A assumes a specific problem without patient input
- Option B focuses on verbalization, not necessarily addressing underlying concerns
- Option C makes assumptions about patient's worries without allowing him to express himself
The cause of death of most AIDS patients who develop multiple opportunistic infections is/are the following: a.Weakened immune system impairs response to therapy
- A. AH of these (a, b, c)
- B. Weakened immune system impairs resistance to infection
- C. Infection cannot be treated effectively
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Most AIDS patients with multiple opportunistic infections die due to a weakened immune system impairing response to therapy. When the immune system is compromised, the body struggles to fight off infections effectively, even with treatment. This results in the infections becoming more severe and ultimately leading to death.
Summary of Other Choices:
B: Weakened immune system impairs resistance to infection - While this is true, it doesn’t directly address the cause of death in AIDS patients with multiple infections.
C: Infection cannot be treated effectively - This is not entirely accurate as infections can be treated, but the weakened immune system hinders the response to treatment.
Overall, Choice A is the most accurate as it directly links the weakened immune system to the inability to respond effectively to therapy, leading to fatal outcomes.
In an individual with Sjogren’s syndrome, nursing care should focus on:
- A. Moisture replacement
- B. Nutritional supplementation
- C. Electrolyte balance
- D. Arrhythmia management
Correct Answer: A
Rationale: The correct answer is A: Moisture replacement. Sjogren's syndrome is an autoimmune disorder that primarily affects the moisture-producing glands, leading to dryness in the eyes, mouth, and other mucous membranes. Nursing care should focus on managing these symptoms by providing moisture replacement through artificial tears, lubricating eye drops, and hydrating mouthwashes. This helps prevent complications such as corneal damage and dental issues. Nutritional supplementation (B) may be needed if there are difficulties in eating due to dry mouth, but it is not the primary focus. Electrolyte balance (C) and arrhythmia management (D) are not directly related to the symptoms of Sjogren's syndrome and are therefore not the main priorities in nursing care for this condition.