Nokea
25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.’s laboratory results indicate bone marrow depression. The nurse should encourage him to:
- A. Sleep with the head of the bed slightly
- B. Use a soft toothbrush and electric razor
- C. Drink citrus juices frequently for nourishment
- D. Increase his activity level and ambulates frequently
Correct Answer: B
Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because:
A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression.
C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding.
D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.
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To return a patient with hyponatremia to normal sodium levels, it is safer to restrict fluid intake than to administer sodium:
- A. In patients who are unconscious
- B. In patients who show neurologic
- C. To prevent fluid overload symptoms
- D. To prevent dehydration
Correct Answer: C
Rationale: Step 1: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood.
Step 2: Restricting fluid intake helps prevent further dilution of sodium in the blood, aiding in correcting hyponatremia.
Step 3: Administering sodium can lead to rapid correction, risking osmotic demyelination syndrome.
Step 4: Choice C is correct as it aligns with the goal of managing hyponatremia by preventing fluid overload symptoms.
Summary: A, B, and D are incorrect as they do not directly address the primary concern of correcting low sodium levels in hyponatremia.
What should a male client over age 50 do to help ensure early identification of prostate cancer?
- A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
- B. Have a transrectal ultrasound every 5 years
- C. Perform monthly testicular self-examinations, especially after age 50
- D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A
Rationale: Rationale:
1. Digital rectal exam (DRE) and PSA test are recommended by major health organizations for prostate cancer screening in men over 50.
2. DRE helps detect abnormalities in the prostate, while PSA test measures the levels of a protein produced by the prostate gland.
3. Prostate cancer can be asymptomatic in its early stages, so regular screening is crucial for early detection and treatment.
4. Transrectal ultrasound is not a primary screening method for prostate cancer.
5. Testicular self-exams are for detecting testicular cancer, not prostate cancer.
6. CBC, BUN, and creatinine levels are not specific tests for prostate cancer screening.
Which nursing action is most appropriate for the weak patient with osteoporosis?
- A. Maintain bedrest
- B. Ambulate with assistance
- C. Encourage fluids
- D. Provide a high-protein diet
Correct Answer: B
Rationale: The correct answer is B: Ambulate with assistance. Ambulating helps prevent further bone loss and strengthens muscles, important for osteoporosis patients. Bedrest can worsen bone density loss. Encouraging fluids and providing a high-protein diet are important for overall health but do not directly address the weakness associated with osteoporosis.
A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
- A. Wash the area with soap and warm water
- B. Leave the skin alone until it is clear
- C. Apply a cream or lotion to the area
- D. Avoid applying creams or lotion to the area
Correct Answer: C
Rationale: The correct answer is C: Apply a cream or lotion to the area. This is because radio-dermatitis is a common side effect of radiation therapy, causing skin irritation and dryness. Applying a cream or lotion helps to moisturize the skin, reduce inflammation, and promote healing. Washing the area with soap can further irritate the skin. Leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions can worsen dryness and discomfort. Overall, applying a suitable cream or lotion is the most effective method to alleviate symptoms and support skin recovery in radio-dermatitis.
Which of the following would indicate that the patient has a normal corneal light reflex?
- A. The eye focuses the image in the center of the pupil.
- B. The eyes converge to focus on the light.
- C. Constriction of both pupils occurs in response to bright light.
- D. Light is reflected at the same spot in both eyes.
Correct Answer: D
Rationale: The correct answer is D because a normal corneal light reflex involves light being reflected at the same spot in both eyes. This indicates that both eyes are aligned properly and focusing light in the same direction. Choice A is incorrect because it refers to accommodation, not the corneal light reflex. Choice B is incorrect as convergence is related to eye movement, not the corneal light reflex. Choice C is incorrect as pupil constriction in response to light is known as the pupillary light reflex, not the corneal light reflex.