Nokea
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. Soap can irritate the skin and exacerbate the risk for impaired skin integrity in a client receiving radiation therapy. By avoiding soap, we minimize the risk of skin breakdown and promote skin healing.
B: Applying talcum powder can actually worsen skin irritation and should be avoided.
C: Wearing a lead apron is not relevant to the nursing diagnosis of risk for impaired skin integrity.
D: Removing thoracic skin markings is not necessary for skin integrity and may disrupt the treatment plan.
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Which of the ff is a sign of urinary retention in older adults with a neurologic deficit?
- A. Amnesia
- B. Hypertension
- C. Hypotension
- D. A behaviour change
Correct Answer: D
Rationale: The correct answer is D, a behavior change. Urinary retention in older adults with a neurologic deficit can manifest as a behavior change, such as increased agitation, confusion, or restlessness due to discomfort from the inability to empty the bladder. Amnesia (A) is memory loss and not directly related to urinary retention. Hypertension (B) and hypotension (C) are related to blood pressure regulation and are not specific signs of urinary retention. In contrast, a behavior change (D) is a common and characteristic sign indicating urinary retention in this population.
A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?
- A. States feels better after talking with family and friends
- B. Consumes high-carbohydrate foods when stressed
- C. Dislikes the support group meetings
- D. Spends most of the day in bed
Correct Answer: A
Rationale: The correct answer is A because stating feeling better after talking with family and friends demonstrates the use of healthy coping skills. This behavior indicates the patient is seeking and utilizing social support, which is crucial for managing stress and emotions effectively in diabetes management. Choices B, C, and D are incorrect because consuming high-carbohydrate foods when stressed can lead to poor blood sugar control, disliking support group meetings indicates avoidance of beneficial support resources, and spending most of the day in bed can contribute to physical and emotional deterioration, rather than effective coping.
Which of the following terms would indicate to the nurse that a substance is toxic to the ear?
- A. Otoplasty
- B. Ototoxic
- C. Otalgia
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Ototoxic. Ototoxic refers to substances that are harmful to the ear, potentially causing hearing loss or damage. The prefix "oto-" specifically relates to the ear. Otoplasty (A) is a surgical procedure to reshape the ear, not related to toxicity. Otalgia (C) refers to ear pain, not toxicity. Tinnitus (D) is a symptom of ringing in the ears, not directly related to toxicity. Therefore, the term "ototoxic" is the best indicator of a substance being toxic to the ear due to its specific reference to ear toxicity.
Serum albumin Is to be administered intravenously to client with ascites, The expected outcome of this treatment will be a decrease in:
- A. Urinary output
- B. Serum ammonia level
- C. Abdominal girth
- D. Hepatic encephalopathy
Correct Answer: C
Rationale: The correct answer is C: Abdominal girth. Serum albumin helps to increase oncotic pressure in the blood vessels, reducing fluid leakage into the abdomen and decreasing ascites, leading to a decrease in abdominal girth. Option A is incorrect because serum albumin does not directly affect urinary output. Option B is incorrect as serum albumin does not directly impact serum ammonia levels. Option D is incorrect because while serum albumin can help improve liver function, it does not directly treat hepatic encephalopathy.
In teaching a female client who is HIV positive about pregnancy, the nurse would know more teaching is necessary when the client says:
- A. “The baby can get the virus from my placenta.”
- B. “I’m planning on starting on birth control pills.”
- C. “Not everyone who has the virus gives birth to a baby who has the virus.”
- D. “I’ll need to have a C-section if I become pregnant and have a baby.”
Correct Answer: B
Rationale: The correct answer is B because starting birth control pills does not protect against HIV transmission to the baby during pregnancy. The other choices demonstrate understanding of HIV transmission risks and prevention methods. A shows awareness of vertical transmission, C recognizes that not all babies born to HIV-positive mothers are infected, and D acknowledges the potential need for a C-section to reduce transmission risk. Starting birth control pills is unrelated to preventing mother-to-child HIV transmission during pregnancy.