Nokea
A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is most important?
- A. Assess blood pressure and pulse.
- B. Attach the client to a pulse oximeter.
- C. Have the client rate his or her pain.
- D. Facilitate urgent radiation therapy.
Correct Answer: A
Rationale: The correct action by the nurse is to assess the client's blood pressure and pulse. Difficulty breathing can be a sign of various conditions, including cardiac issues. Assessing blood pressure and pulse helps in determining the client's hemodynamic status and identifying any cardiovascular compromise. Option B is less crucial as attaching the client to a pulse oximeter may provide oxygen saturation levels but does not directly assess cardiac output. Option C is not the priority in this situation as the client's difficulty breathing is a more urgent concern. Option D is incorrect as urgent radiation therapy is not indicated based on the client's presentation.
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An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurse's most appropriate response to the patient's complaint?
- A. Call 911.
- B. Promptly refer the patient for medical assessment.
- C. Facilitate a radiograph of the patient's neck and have the results forwarded to the patient's primary care provider.
- D. Encourage the patient to track the size of the lymph node and seek care in 1 week.
Correct Answer: B
Rationale: The most appropriate response for a patient presenting with a firm, painless cervical lymph node and denying recent infectious diseases is to promptly refer the patient for medical assessment. This is crucial to rule out serious underlying conditions such as malignancy or other concerning causes. Calling 911 is not necessary in this situation as it is not an emergency. Ordering a radiograph may not be the most immediate or appropriate action, as further evaluation by a healthcare provider is needed first. Encouraging the patient to wait and track the lymph node for a week is not advisable when a potential serious condition needs to be ruled out promptly.
The nurse is caring for a patient who has just been given a 6-month prognosis following a diagnosis of extensive-stage small-cell lung cancer. The patient states that he would like to die at home, but the team believes that the patient's care needs are unable to be met in a home environment. What might you suggest as an alternative?
- A. Discuss a referral for rehabilitation hospital.
- B. Panel the patient for a personal care home.
- C. Discuss a referral for acute care.
- D. Discuss a referral for hospice care.
Correct Answer: D
Rationale: In this scenario, the most appropriate alternative to address the patient's desire to die at home while ensuring proper care is hospice care. Hospice care is specifically designed to provide support to patients and families in situations where the patient's needs cannot be met at home. Rehabilitation hospital (Choice A), personal care home (Choice B), and acute care (Choice C) are not the most suitable options in this case as they do not focus on end-of-life care and support like hospice care does.
A patient from the oncology unit asks the nurse about metastasis. Which of the following statements by the nurse requires immediate intervention by the head nurse?
- A. Metastasis is the replication of cells
- B. Metastasis can happen in most parts of the body
- C. The replication of cancer cells and travel from one area to another
- D. Metastasis is the spread of cancer cells
Correct Answer: A
Rationale: The correct answer is A because metastasis refers to the spread of cancer cells to distant parts of the body, not the replication of cells. Choice B is correct as metastasis can indeed occur in various body parts. Choice C is incorrect as it inaccurately combines the concepts of replication and travel of cancer cells. Choice D is also correct as it accurately defines metastasis as the spread of cancer cells.
A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patient's family and friends?
- A. Your family should gather at the bedside in case there is a negative outcome.
- B. Ensure she abstains from eating any food 24 hours before the procedure.
- C. Wear a hospital gown when entering the patient's room.
- D. Avoid visiting if you've had a recent infection.
Correct Answer: D
Rationale: The correct answer is D: 'Avoid visiting if you've had a recent infection.' Before a hematopoietic stem cell transplantation, it is essential for visitors to refrain from visiting if they have had a recent illness or vaccination to minimize the risk of infection to the patient. Choice A is incorrect because emphasizing a negative outcome is not beneficial to the patient or their family. Choice B is incorrect as it is not necessary to abstain from food for a hematopoietic stem cell transplantation. Choice C is irrelevant to the situation as wearing a hospital gown is not the key information for family and friends to be aware of.
Gastric cancer is known to have numerous risk factors. Which of the following is not a risk factor?
- A. Diet high in sodium
- B. Diet with high amounts of chili garlic
- C. Smoking
- D. Diet high in fiber
Correct Answer: D
Rationale: A diet high in fiber is not a risk factor for gastric cancer; in fact, it is generally considered protective against cancers. High sodium intake (Choice A) has been associated with an increased risk of gastric cancer. Diets with high amounts of chili garlic (Choice B) may irritate the stomach lining, potentially contributing to the development of gastric cancer. Smoking (Choice C) is a well-established risk factor for various types of cancers, including gastric cancer.