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A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, NO, MO. What does this classification mean?
- A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
- B. Carcinoma is situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
- C. Can't assess tumor or regional lymph nodes and no evidence of metastasis
- D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
Correct Answer: B
Rationale: In the TNM staging system, "T" represents the extent of the primary tumor, "N" refers to the involvement of regional lymph nodes, and "M" indicates the presence of distant metastasis. In the given classification of TIS, N0, M0:
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The physical abuse of children by parents affects children of all ages. It is estimated that 1% to 2% of children are physically abused during childhood and that significant number of them are fatally injured each year. Of the following, the second LEADING cause of mortality from physical abuse is
- A. rib fractures
- B. head trauma
- C. abdominal injury
- D. hot tap water burn
Correct Answer: B
Rationale: Head trauma is a leading cause of mortality in abused children, as it can result in severe brain damage or death.
What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)?
- A. Explain how SIDS could have been predicted and prevented. TestBankWorld.org
- B. Interview parents in depth concerning the circumstances surrounding the child's death.
- C. Discourage parents from making a last visit with the infant.
- D. Make a follow-up home visit to parents as soon as possible after the child's death.
Correct Answer: D
Rationale: One of the most important nursing responsibilities when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS) is to provide ongoing support and care to the grieving parents. Making a follow-up home visit as soon as possible after the child's death allows the nurse to offer emotional support, assess the parents' well-being, provide information on coping strategies, and refer them to appropriate resources such as counseling services or support groups. This visit also enables the nurse to address any questions or concerns the parents may have, validate their feelings of grief, and help them navigate the difficult grieving process. By being present and available to the family during this challenging time, the nurse can help them feel supported and cared for as they cope with the tragic loss of their infant.
A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
- A. Continue with the bath and tell the client not to worry
- B. Ask the physician to obtain a psychiatric consultation
- C. Listen and show interest as the client expresses feelings
- D. State that these friends's behavior shows that they aren't true friends
Correct Answer: C
Rationale: It is important for the nurse to listen and show interest as the client expresses their feelings in this situation. The client's emotional distress is a valid response to feeling abandoned by friends and family during a difficult time. By providing a supportive and empathetic presence, the nurse can help the client feel valued and understood, promoting emotional well-being and potentially increasing the client's sense of comfort and trust in the healthcare setting. This approach validates the client's feelings and fosters therapeutic communication, which is crucial in providing holistic care to individuals with complex health needs such as AIDS and Pneumocystis carinii pneumonia. It is essential to acknowledge and address the client's emotional needs in addition to their physical care.
Which of the following data would be included in a health history? (Select all that apply.)
- A. Review of systems
- B. Physical assessment
- C. Sexual history
- D. Growth measurements
Correct Answer: A
Rationale: A health history is a comprehensive compilation of information about a patient's health status, medical conditions, and pertinent background information. The selected data that would be included in a health history includes:
Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?
- A. Fruity odor of the breath
- B. shallow, deep respirations
- C. severe dehydration
- D. profuse sweating
Correct Answer: C
Rationale: In a patient with hyperglycemic, hyperosmolar nonketotic coma (HHNK), the high blood glucose levels lead to osmotic diuresis, causing excessive urination and subsequent dehydration. Dehydration can manifest as symptoms such as dry mucous membranes, poor skin turgor, decreased urine output, increased heart rate, and low blood pressure. Therefore, the nurse should expect to find signs of severe dehydration in a patient with HHNK coma. The other options listed are not typical assessment findings associated with HHNK coma.