Nokea
A 56-year-old female who is receiving radiation therapy tells the nurse that she feels inadequate as a wife and mother because she can no longer carry out her usual duties with the same energy as before. What recommendations should the nurse make to help the client cope with this situation?
- A. Suggest that she reassign all household chores to other members of the family.
- B. Suggest that she prioritize her activities and ask for help from friends and family.
- C. Suggest that she ignore the household chores during the crisis period.
- D. Tell her not to worry so much because everyone gets a little tired at this phase of the therapy.
Correct Answer: B
Rationale: Prioritizing activities and seeking help from friends and family helps the client manage her energy and responsibilities, reducing feelings of inadequacy.
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The nurse should instruct the client with a platelet count of less than 150,000/µL to avoid which of the following activities?
- A. Ambulation.
- B. Valsalva's maneuver.
- C. Visiting with children.
- D. Semi-Fowler's position.
Correct Answer: B
Rationale: A platelet count below 150,000/µL indicates thrombocytopenia, increasing bleeding risk. Valsalva's maneuver (e.g., straining during bowel movements) can raise intracranial pressure and cause bleeding, such as cerebral hemorrhage, and should be avoided. Ambulation, visiting children, and semi-Fowler's position are generally safe unless other conditions are present.
Which of the following describes decerebrate posturing?
- A. Internal rotation and adduction of arms with the excess, wrists, and fingers.
- B. Back hunched with the position of all four extremities with supination of arms and plantar flexion of feet.
- C. Supination of arms, dorsiflexion of the feet.
- D. Back arched, rigid extension of all four extremities.
Correct Answer: D
Rationale: Decerebrate posturing involves rigid extension of all extremities with arched back, indicating severe brain stem dysfunction. The other options describe decorticate posturing or incorrect combinations of movements.
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
- A. Cardiac arrest.
- B. Pulmonary edema.
- C. Circulatory collapse.
- D. Hemorrhage.
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.
A nurse is assessing a female who is receiving the second administration of chemotherapy for breast cancer. When obtaining this client's health history, what is the most important information the nurse should obtain?
- A. Has your hair been falling out in clumps?
- B. Have you had nausea or vomiting?
- C. Have you been sleeping at night?
- D. Do you have your usual energy level?
Correct Answer: B
Rationale: Nausea and vomiting are critical to assess during chemotherapy, as they can lead to dehydration, malnutrition, and treatment delays if not managed promptly.
After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following?
- A. Elevate the sequential compression device (SCD) on two pillows.
- B. Change the settings on the SCD to make the client more comfortable.
- C. Use the SCD to remove dressings and bathe the leg.
- D. Discontinue the SCD when the client is ambulatory.
Correct Answer: D
Rationale: The SCD is discontinued when the client is ambulatory, as mobility reduces the risk of thrombosis.