Nokea
A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem?
- A. The patient requests that her family bring her makeup and wig.
- B. The patient begins to discuss the future with her family.
- C. The patient reports less disruption from pain and discomfort.
- D. The patient cries openly when discussing her disease.
Correct Answer: B
Rationale: The correct answer is B because discussing the future indicates acceptance and hope, a positive step towards improved body image and self-esteem. The patient is focusing on moving forward, which shows emotional growth and resilience. Choice A may provide temporary comfort but does not necessarily address underlying emotional issues. Choice C is related to pain management, not body image or self-esteem. Choice D suggests continued emotional distress rather than progress towards improved self-image.
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Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the
- A. direct Coombs test of twin A.
- B. direct Coombs test of twin B.
- C. indirect Coombs test of the mother.
- D. transcutaneous bilirubin level for both twins.
Correct Answer: C
Rationale: The correct answer is C: indirect Coombs test of the mother. This test is crucial to determine if the mother has developed antibodies against the Rh-positive blood of twin A, which could lead to hemolytic disease of the newborn in future pregnancies. A direct Coombs test of twin A or twin B is not relevant in this scenario as it does not provide information about the mother's antibody status. Transcutaneous bilirubin levels are used to monitor jaundice in newborns and not related to Rh incompatibility. In summary, the indirect Coombs test of the mother is the most relevant test to assess the risk of hemolytic disease in future pregnancies.
A 45-year-old woman has just undergone a radical hysterectomy for invasive cervical cancer. Prior to the surgery the physician explained to the patient that after the surgery a source of radiation would be placed near the tumor site to aid in reducing recurrence. What is the placement of the source of radiation called?
- A. Internal beam radiation
- B. Trachelectomy
- C. Brachytherapy
- D. External radiation
Correct Answer: C
Rationale: The correct answer is C: Brachytherapy. Brachytherapy involves placing a radiation source near or directly into the tumor site. In this case, after the hysterectomy, the source of radiation is placed near the cervical cancer site to deliver targeted radiation therapy. This method helps reduce the risk of cancer recurrence by delivering high doses of radiation to the tumor while minimizing exposure to surrounding healthy tissues.
Choice A (Internal beam radiation) typically refers to a type of external radiation therapy where radiation beams are directed at the tumor from outside the body, not placed internally like brachytherapy.
Choice B (Trachelectomy) is a surgical procedure that involves removal of the cervix while preserving the uterus, not related to radiation therapy.
Choice D (External radiation) involves delivering radiation from outside the body using a machine, unlike brachytherapy where the radiation source is placed internally near the tumor site.
The nurse is caring for patients with ostomies.In which ostomy location will the nurse expect very liquid stool to be present?
- A. Sigmoid
- B. Transverse
- C. Ascending
- D. Descending
Correct Answer: C
Rationale: The correct answer is C: Ascending. Stool consistency varies based on the location of the ostomy. The ascending colon is responsible for absorbing water from stool, so an ostomy in this location will have very liquid stool. Sigmoid, transverse, and descending colons are responsible for further solidifying stool, so ostomies in those locations would not typically have very liquid stool.
A nurse is preparing to document a patient whohas chest pain. Which information is critical for the nurse to include?
- A. The family is a “pain.”
- B. Pupils equal and reactive to light
- C. Had poor results from the pain medication
- D. Sharp pain of 8 on a scale of 1 to 10
Correct Answer: D
Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?
- A. Salmonella infection
- B. Mycobacterium tuberculosis
- C. Clostridium difficile
- D. Pneumocystis pneumonia
Correct Answer: D
Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.