Nokea
A client tells the nurse that her bra fits more snugly at certain times of the month and she is concerned this may be a sign of breast cancer. The best response for the nurse is to explain that:
- A. A change in breast size should be checked by her physician.
- B. Benign cysts tend to cause the breast to vary in size.
- C. It is normal for the breast to increase in size before menstruation begins.
- D. A difference in the size of her breasts is related to normal growth and development.
Correct Answer: C
Rationale: Breast size increases before menstruation due to hormonal changes, which is normal.
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Select the risk factor that is accurately paired with its disorder.
- A. Hypernatremia: Hepatic failure
- B. Hypocalcemia: Vitamin A deficiency
- C. Hypermagnesemia: Cushing's disease
- D. Hypomagnesemia: Crohn's disease
Correct Answer: D
Rationale: Hypomagnesemia is associated with Crohn's disease due to malabsorption and chronic diarrhea, which lead to magnesium loss.
A woman with a history of a left radical mastectomy is being admitted for abdominal surgery. The nurse should:
- A. Take the blood pressure only in the unaffected arm.
- B. Start an I.V. line in the affected arm.
- C. Encourage a dependent position of the affected arm.
- D. Allow blood draws in the affected arm.
Correct Answer: A
Rationale: Due to lymphedema risk post-mastectomy, blood pressure, I.V. lines, and blood draws should be avoided in the affected arm.
The nurse is caring for a young adult client diagnosed with sarcoidosis. The client is angry and tells the nurse that there is no point in learning disease management because there is no possibility of ever being cured. Based on the client's statement, the nurse determines that the client is experiencing which potential problem?
- A. Apprehension
- B. Powerlessness
- C. Intellectualization
- D. Ineffective thought process
Correct Answer: B
Rationale: The client with powerlessness expresses feelings of having no control over a situation or outcome. Apprehension is fearful or uneasy anticipation of something. Intellectualization is excessive reasoning to avoid feeling. Ineffective thought process involves interruption in normal thought.
A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted to the hospital outpatient clinic for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status the nurse should review the results of which of the following tests?
- A. Red blood cell count.
- B. Direct and indirect bilirubin levels.
- C. Reticulocyte count.
- D. Albumin level.
Correct Answer: D
Rationale: Albumin levels reflect nutritional status, as low levels indicate protein malnutrition, common in cancer patients. The other tests assess hematologic or liver function.
A client is admitted to the hospital in sickle cell crisis. For which clinical indicator should the nurse monitor the client?
- A. Pain
- B. Diarrhea
- C. Bradycardia
- D. Blurred vision
Correct Answer: A
Rationale: Sickle cell crisis usually causes severe pain in the bones and joints along with joint swelling. The pain develops as a result of microvascular occlusion from abnormal sickled hemoglobin that occurs with hypoxia. Therapy includes pain management with opioid analgesics, supplemental oxygen, and intravenous fluids. The remaining options are not associated with sickle cell crisis.