Nokea
A client is undergoing radiation therapy for treatment of thyroid cancer. Following the radiation, the client develops xerostomia. Which of the following best describes this condition?
- A. Cracks in the corners of the mouth
- B. Peeling skin from the tongue and gums
- C. Increased dental caries
- D. Dry mouth
Correct Answer: D
Rationale: Xerostomia, also known as dry mouth, is a common side effect of radiation therapy in the head and neck region. It occurs when the salivary glands are damaged during treatment, reducing saliva production and causing a dry sensation in the mouth. The correct answer is 'Dry mouth' (option D). Choice A, 'Cracks in the corners of the mouth,' describes angular cheilitis, a condition linked to nutritional deficiencies or candida infection. Choice B, 'Peeling skin from the tongue and gums,' is more indicative of conditions like oral thrush or mucositis. Choice C, 'Increased dental caries,' is a consequence of reduced saliva flow but does not specifically describe xerostomia.
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The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
- A. A large air leak in the water-seal chamber
- B. 400 mL of blood in the collection chamber
- C. Complaint of pain with each deep inspiration
- D. Subcutaneous emphysema at the insertion site
Correct Answer: B
Rationale: The nurse should be most concerned if 400 mL of blood is observed in the collection chamber as it may indicate the patient is at risk of developing hypovolemic shock. A large air leak in the water-seal chamber is expected initially after chest tube placement for a pneumothorax. While pain with deep inspiration should be treated, it is not as urgent as the risk of continued hemorrhage. Subcutaneous emphysema is not uncommon in a patient with pneumothorax and is usually harmless. However, a large amount of blood in the collection chamber is a more critical finding that requires immediate attention to prevent potential complications.
The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
- A. Hepatitis testing
- B. Tuberculosis screening
- C. Contraceptive teaching
- D. Colonoscopy information
Correct Answer: B
Rationale: Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.
The nurse is reviewing the characteristics of culture. Which statement is correct regarding the development of one's culture?
- A. Learned through language acquisition and socialization.
- B. Genetically determined on the basis of racial background.
- C. A nonspecific phenomenon and is adaptive but unnecessary.
- D. Biologically determined on the basis of physical characteristics.
Correct Answer: A
Rationale: Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It is not biologically or genetically determined, but rather acquired through social interactions. The correct answer, 'Learned through language acquisition and socialization,' aligns with the understanding that culture is a learned behavior. Choices B, C, and D are incorrect because culture is not genetically determined, nonspecific, or biologically based on physical characteristics. Understanding that culture is acquired through language and socialization is essential for healthcare providers to provide culturally competent care.
The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which items will the nurse include in the teaching plan? (Select one that does not apply.)
- A. Apply splints and braces to facilitate muscle control.
- B. Buy toys that are appropriate for the child's abilities.
- C. Encourage the child to perform self-care tasks.
- D. Use skeletal muscle relaxants for short-term control.
Correct Answer: D
Rationale: When developing a discharge teaching plan for a child with cerebral palsy (CP), the nurse should focus on strategies to enhance the child's independence and functional abilities. Choices A, B, and C are appropriate interventions to include in the teaching plan for a child with CP. Applying splints and braces can help facilitate muscle control and improve body functioning. Buying toys that are appropriate for the child's abilities can promote engagement and development. Encouraging the child to perform self-care tasks fosters independence and skill development. However, the use of skeletal muscle relaxants for short-term control is not typically a part of routine care for pediatric patients with CP. These medications are usually reserved for specific situations and are not a standard component of home care teaching plans for children with CP.
Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select one that does not apply)
- A. Age
- B. Blood pressure
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: D
Rationale: The correct answer is 'Oxygen saturation.' When calculating the CURB-65 score for a patient with pneumonia, the factors considered include mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). Oxygen saturation is not used in the CURB-65 scoring system. While blood pressure, respiratory rate, and age are factors that are used in the calculation of the CURB-65 score, oxygen saturation is not part of the scoring criteria. Therefore, oxygen saturation is the factor that does not apply when calculating the CURB-65 score.