Nokea
A client diagnosed with endometrial cancer is receiving brachytherapy. Which interventions should the nurse anticipate for this client? Select all that apply.
- A. Cluster care to limit each staff member's time in the room
- B. Instruct the client to be up and around in the room but not to leave the room
- C. Remind family members and visitors to limit close contact with the client
- D. Use protective shielding, if available, when providing direct client care
- E. Wear a radiation badge while in the client's room to measure radiation exposure
Correct Answer: A,C,D,E
Rationale: Brachytherapy involves internal radiation, requiring precautions to minimize exposure. Clustering care (A) reduces staff exposure time. Limiting visitor contact (C) protects others from radiation. Protective shielding (D) and radiation badges (E) ensure safety and monitor exposure. Ambulation (B) is restricted to prevent dislodging the radiation source.
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The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?
- A. Low tar cigarettes are less harmful during pregnancy
- B. There is a relationship between smoking and low birth weight
- C. The placenta serves as a barrier to nicotine
- D. Moderate smoking is effective in weight control
Correct Answer: B
Rationale: There is a relationship between smoking and low birth weight. Smoking reduces placental blood flow, contributing to fetal hypoxia and low birth weight.
The nurse is caring for a client with anorexia nervosa. Which of the following findings would be consistent with the condition? Select all that apply.
- A. Heat intolerance
- B. Has not menstruated in 3 months
- C. Avoids participation in physical activity
- D. Fine, downy hair on the face and back
- E. Decreased serum potassium level
- F. BMI of 16 kg/m²
Correct Answer: B,D,E,F
Rationale: Anorexia nervosa is characterized by severe weight loss and malnutrition, leading to specific clinical findings. Amenorrhea (B) results from hormonal imbalances due to low body fat. Lanugo (D), fine downy hair, develops as a compensatory mechanism for heat loss. Hypokalemia (E) occurs due to starvation or purging behaviors. A BMI of 16 kg/m² (F) indicates severe underweight status, consistent with anorexia. Heat intolerance (A) is more typical of hyperthyroidism, and avoiding physical activity (C) is incorrect as clients often engage in excessive exercise.
The nurse caring for a client with anemia recognizes which clinical manifestation as one specific for a hemolytic type of anemia?
- A. Jaundice
- B. Anorexia
- C. Tachycardia
- D. Fatigue
Correct Answer: A
Rationale: The destruction of red blood cells causes the release of bilirubin, leading to the yellow hue of the skin. Answers C and D occur with anemia but are not specific to hemolytic. Answer B does not relate.
After a recent outbreak of varicella in an elementary school, the practical nurse is assisting with the development of an informative letter to parents. Which of the following instructions are appropriate to include? Select all that apply.
- A. Apply calamine lotion to soothe lesions
- B. Clip your child’s fingernails short
- C. Ensure that your child’s vaccinations are up to date
- D. Keep your child home until lesions have crusted
- E. Place mittens on your child’s hands when sleeping
Correct Answer: A,B,C,D,E
Rationale: Calamine lotion (A) relieves itching, short nails (B) and mittens (E) prevent scratching, vaccinations (C) protect against future infection, and isolation until crusted (D) prevents transmission. All are appropriate.
The office nurse receives 4 telephone messages from clients. Which client does the nurse anticipate as the priority for treatment?
- A. 20-year-old college student who reports a ringlike, red bull’s-eye-shaped, itchy leg rash after hiking in the woods 2 days ago
- B. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching
- C. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago
- D. 86-year-old with gout who is prescribed colchicine and reports diarrhea and not feeling well
Correct Answer: C
Rationale: Headaches and gait disturbance in a 78-year-old on warfarin post-fall (C) suggest a possible subdural hematoma, a life-threatening condition requiring immediate evaluation. Bull’s-eye rash (A) suggests Lyme disease, vaginal discharge (B) indicates yeast infection, and diarrhea (D) is a colchicine side effect, all less urgent.