Nokea
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self- examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. Mobile mass that is soft and easily
- C. Non-mobile mass with irregular edges delineated
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C: Non-mobile mass with irregular edges delineated. This finding strongly suggests cancer as non-mobile masses with irregular edges are characteristic of malignant tumors. Cancerous lumps tend to be fixed in place due to involvement of surrounding tissues. Irregular edges indicate potential invasive growth. Choices A and B describe characteristics more commonly associated with benign masses. Eversion of the nipple is concerning for cancer but not specific enough to strongly suggest malignancy. Choice D indicates absence of lymph node involvement, which is not directly related to the characteristics of the breast lump.
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A patient understands the common causes of urinary tract infection if he or she states the following, EXCEPT:
- A. “UTI can be caused by holding the urge to urinate.”
- B. “Insertion of instruments and catheter to the urinary tract can introduce bacteria that can cause infection.”
- C. “I usually drink lots of water at night and it might have caused my UTI.”
- D. “UTI can be caused by unhygienic cleaning after defecation.”
Correct Answer: C
Rationale: Rationale: Choice C is the correct answer because drinking lots of water at night actually helps prevent UTIs by flushing out bacteria from the urinary tract. Holding the urge to urinate (Choice A) can increase the risk of UTIs as bacteria can multiply in stagnant urine. Insertion of instruments and catheters (Choice B) can introduce bacteria, leading to infection. Unhygienic cleaning after defecation (Choice D) can also introduce bacteria to the urinary tract, causing UTIs. Therefore, Choice C is the exception as it does not contribute to the common causes of UTIs.
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The correct answer is C: Acute pain. This is the most pertinent nursing diagnosis because the patient has a right femur fracture and reports moderate discomfort. The priority is to address the acute pain associated with the fracture. Posttrauma syndrome (A) typically involves a broader range of emotional and psychological responses beyond just moderate discomfort. Constipation (B) is not the priority in this case, as it is not directly related to the patient's current condition. Anxiety (D) may be present but addressing the acute pain takes precedence in this situation to ensure the patient's comfort and well-being.
Which of the ff is the best dietary advice to maximize the immune function in healthy people?
- A. Include immune enhancing formulas
- B. Avoid polyunsaturated fatty acids
- C. Increase intake of essential fatty acids and omega 3 fatty acids
- D. Follow a balanced and varied diet CARING FOR CLIENT WITH IMMUNE MEDIATED DISORDERS
Correct Answer: D
Rationale: Step-by-step rationale:
1. A balanced and varied diet provides essential nutrients for immune function.
2. Including a wide range of foods ensures intake of vitamins, minerals, and antioxidants crucial for immune health.
3. Avoiding extremes like excessive immune-enhancing formulas or eliminating polyunsaturated fatty acids maintains balance.
4. Essential fatty acids and omega-3 fatty acids are beneficial but should be part of a well-rounded diet.
5. For clients with immune-mediated disorders, individualized dietary advice may be necessary.
Summary:
- A: Immune-enhancing formulas may not be necessary and could disrupt balance.
- B: Avoiding all polyunsaturated fatty acids is not advisable as some are essential for health.
- C: Increasing essential fatty acids is beneficial but should be part of a balanced diet.
When the nurse is reviewing a patient’s daily laboratory test results, which of the ff. electrolyte imbalances should the nurse recognize as predisposing the patient to digoxin toxicity?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: A
Rationale: Step-by-step rationale:
1. Digoxin toxicity can be potentiated by hypokalemia due to the risk of enhanced cardiac toxicity.
2. Hypokalemia can lead to increased sensitivity of cardiac cells to digoxin.
3. Low potassium levels can disrupt the sodium-potassium ATPase pump, enhancing digoxin's effects.
4. The nurse should recognize hypokalemia as a predisposing factor for digoxin toxicity.
Summary:
A: Hypokalemia is the correct answer as it enhances digoxin toxicity by affecting cardiac function.
B: Hyponatremia does not directly predispose to digoxin toxicity.
C: Hyperkalemia is not a predisposing factor and can actually counteract digoxin's effects.
D: Hypernatremia is not directly related to digoxin toxicity.
Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?
- A. New set of tracheostomy tubes and Oxygen tank
- B. Theophylline and Epinephrine
- C. Obturator and Kelly clamp
- D. Sterile saline dressing
Correct Answer: A
Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank.
Rationale:
1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway.
2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted.
Summary of incorrect choices:
B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy.
C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation.
D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.