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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: Step 1: TIS stands for carcinoma in situ, which means cancer cells are present only in the layer of cells where they first developed.
Step 2: N0 indicates no abnormal regional lymph nodes are involved.
Step 3: M0 signifies no evidence of distant metastasis.
Therefore, the correct answer is B because it accurately interprets the TNM staging system for the biopsy report.
Summary:
A: Incorrect - TIS indicates carcinoma in situ, not no evidence of primary tumor.
C: Incorrect - TIS already assesses tumor presence, ruling out this option.
D: Incorrect - TIS is not about ascending degrees of distant metastasis.
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Why does emotional counselling or helping the client perform common daily activities become important nursing care interventions in clients with Parkinson’s or Huntington’s diseases, or even epilepsy?
- A. Because clients suffer from depression, anxiety, and inability to perform basic self care
- B. Because clients become paralytic throughout the body
- C. Because the clients bone become weak, brittle, and painful to even move
- D. Because clients generally become very aggressive and violent with other people CARING FOR CLIENTS WITH NEUROLOGIC DEFICITS
Correct Answer: A
Rationale: The correct answer is A because clients with Parkinson's, Huntington's diseases, or epilepsy often experience emotional challenges such as depression and anxiety due to the impact of their conditions on their daily lives. Emotional counseling helps address these issues. Additionally, these clients may struggle with basic self-care activities due to motor and cognitive deficits, making it crucial for nurses to assist them in performing daily tasks.
Choice B is incorrect as clients with these conditions may experience paralysis or motor impairments, but it is not a universal symptom. Choice C is incorrect because the question does not mention bone issues in Parkinson's, Huntington's diseases, or epilepsy. Choice D is incorrect as aggression and violence are not common symptoms in clients with these neurologic deficits.
The adrenal cortex is responsible for producing which substances?
- A. Glucocortocoids and androgens
- B. Mineralocortiroids and
- C. Catecholamines and epinephrine catecholamines
- D. Norepinephine and epinephrine
Correct Answer: A
Rationale: The correct answer is A: Glucocorticoids and androgens. The adrenal cortex is divided into three layers, with the outer layer responsible for producing mineralocorticoids like aldosterone, the middle layer producing glucocorticoids like cortisol, and the inner layer producing androgens. Glucocorticoids are essential for regulating metabolism and immune response, while androgens are male sex hormones. Choices B, C, and D are incorrect because mineralocorticoids, catecholamines, norepinephrine, and epinephrine are produced by different parts of the adrenal gland, not specifically by the adrenal cortex.
The nurse assesses for the characteristic movement of Parkinson’s disease which is a (n):
- A. Exaggerated muscle flaccidity that leads to frequent falls
- B. Hyperextension of the back and neck that alters normal movements
- C. Pronation- supination of the hand and forearm that interferes with normal hand activities
- D. Combination of all of the above
Correct Answer: C
Rationale: The correct answer is C because pronation-supination of the hand and forearm is a characteristic movement in Parkinson's disease called "pill-rolling tremor." This movement interferes with normal hand activities due to involuntary shaking.
A is incorrect because exaggerated muscle flaccidity does not lead to frequent falls in Parkinson's disease. B is incorrect as hyperextension of the back and neck is not a characteristic movement of Parkinson's disease. D is incorrect as it combines all options, which is not accurate.
Which of the following groups of terms best describes a nurse-initiated intervention?
- A. Dependent, physician-ordered, recovery
- B. Autonomous, clinical judgment, client outcomes
- C. Medical diagnosis, medication administration
- D. Other health care providers, skill acquisition
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.
The LPN is caring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states, “I know I am not going to wake up after surgery.” Which of the following actions should the nurse take?
- A. Reassure patient everything will be all right
- B. Explain national surgery death rate
- C. Inform the registered nurse
- D. Ask family to comfort the patient
Correct Answer: C
Rationale: The correct answer is C: Inform the registered nurse. This is the best course of action as the LPN should escalate the situation to a higher level of care by involving the registered nurse who can further assess the patient's concerns and provide appropriate interventions.
A. Reassuring the patient may not address the underlying fear and may not be sufficient to alleviate their anxiety.
B. Providing statistics about surgery death rates may further escalate the patient's fears and anxiety, causing more harm than good.
D. Involving the family to comfort the patient may not address the patient's specific concerns and may not be within the family's scope of understanding or expertise to effectively address the situation.
Informing the registered nurse allows for a more comprehensive assessment and appropriate intervention to address the patient's fears and concerns in a holistic manner.