Nokea
A 57-year-old client has difficulty with mobility after cancer treatment therapies and states, 'Why should I bother stretching my muscles? It doesn't seem to make any difference what I do.' The nurse responds by helping the client establish reasonable activity goals, choose their own health care from the menu, and make choices about her daily activities. These interventions represent the nurse's attempt to address which of the following nursing diagnoses?
- A. Ineffective coping.
- B. Powerlessness.
- C. Risk prone health behavior.
- D. Complicated grieving.
Correct Answer: B
Rationale: The client's statement reflects powerlessness, and the nurse's interventions aim to restore a sense of control through goal-setting and decision-making.
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The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation?
- A. Use of alcohol.
- B. Frequent use of mouthwash.
- C. Lack of vitamin B12.
- D. Lack of regular teeth cleaning by a dentist.
Correct Answer: A
Rationale: Alcohol use is a well-established primary risk factor for oral cancer, often acting synergistically with tobacco use. Frequent mouthwash use, vitamin B12 deficiency, and lack of dental cleanings are not primary risk factors for oral cancer.
A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal?
- A. Zyban (Bupropion)
- B. Nicotine (Nicotrol)
- C. Nitroglycerin (Tridil)
- D. Ibuprofen (Advil)
Correct Answer: A
Rationale: Zyban (bupropion) is an antidepressant that reduces nicotine cravings and withdrawal symptoms, making it effective for smoking cessation in Buerger's disease. Nicotine replacement (Nicotrol) may help but continues nicotine exposure, nitroglycerin is for angina, and ibuprofen is irrelevant.
The son of a 78-year-old client with metastatic prostate cancer is asking the nurse about the purpose of hospice care. Which of the following statements by the nurse best describes hospice care?
- A. Hospice care uses a team approach to direct hospice activity.
- B. Clients and their families are the focus of care.
- C. The client's physician coordinates all the care.
- D. All hospice clients will die at home.
Correct Answer: B
Rationale: Hospice care focuses on the client and family, providing holistic support to enhance quality of life and comfort during the end-of-life phase.
Contraindications to the administration of tissue plasminogen activator (t-PA) include which of the following?
- A. Age greater than 60 years.
- B. History of cerebral hemorrhage.
- C. History of heart failure.
- D. Cigarette smoking.
Correct Answer: B
Rationale: A history of cerebral hemorrhage is an absolute contraindication to t-PA due to the risk of bleeding. Age, heart failure, and smoking are not contraindications.
The nurse is planning a staff development conference about medication safety. Which of the following medications should have a second medication check prior to administration? Select all that apply.
- A. heparin infusion
- B. regular insulin
- C. 0.9% sodium chloride (normal saline) flush
- D. patient-controlled analgesia (PCA)
- E. oxytocin infusion
- F. total parenteral nutrition
Correct Answer: A,B,D,E,F
Rationale: High-risk medications like heparin, insulin, PCA, oxytocin, and TPN require a second check to prevent errors.