Nokea
A client who has undergone radiation therapy presents with itching, redness, burning pain, and skin sloughing on the chest and abdomen. Which nursing intervention is most appropriate for this client?
- A. Apply ointment to the skin to avoid moisture
- B. Wash the area gently with water and pat dry
- C. Use a mild antiseptic soap to wash the area and pat dry
- D. Apply talcum powder to keep the skin dry
Correct Answer: B
Rationale: For a client experiencing skin symptoms like redness, itching, burning pain, and sloughing after radiation therapy, it is crucial to maintain proper skin care. Applying ointments, lotions, or powders can worsen the condition by trapping moisture and leading to further skin irritation. The most appropriate intervention is to wash the affected area gently with water to cleanse it without further irritating the skin. Using mild antiseptic soap or talcum powder can also be harsh on the compromised skin. Patting the skin dry helps prevent friction and trauma to the affected area, promoting healing and comfort.
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In educating clients on ways to manage pain, which topic can be appropriately delegated to an LPN/LVN who will continue under supervision?
- A. Acupuncture
- B. Guided Imagery
- C. Alternating Rest/Activity
- D. Over-the-counter medications
Correct Answer: C
Rationale: The correct answer is 'Alternating Rest/Activity.' This topic falls within the nursing scope of practice and is typically covered in the training and education of all nurses, including LPN/LVNs. Educating clients on alternating rest and activity is safe, straightforward, and a standard non-pharmacological pain management strategy. Acupuncture (Choice A) and Guided Imagery (Choice B) involve specific skills and techniques that are typically outside the scope of practice for LPN/LVNs. Over-the-counter medications (Choice D) may require additional assessment, monitoring, and considerations that are beyond the usual delegation for LPN/LVNs.
The parents of a newborn with hypospadias are reviewing the treatment plan with the nurse. Which statement by the parents indicates their understanding of the plan?
- A. Caution should be used when straddling my infant on a hip.
- B. Vital signs should be taken daily to check for bladder infection.
- C. Catheterization will be necessary when my infant does not void.
- D. Circumcision has been delayed to save tissue for surgical repair.
Correct Answer: D
Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. It's important not to circumcise the infant, as the dorsal foreskin tissue will be required for surgical repair of the hypospadias. Option A is unrelated to the treatment plan for hypospadias. Option B is not directly related to the surgical repair of hypospadias. Option C is not a routine part of the treatment plan for hypospadias, as catheterization is usually managed by healthcare professionals.
A nurse is caring for a client who was recently diagnosed with breast cancer. The oncologist uses the TNM staging system to classify this case as T2, N2, M0. The nurse understands that TNM stands for:
- A. Tumor, Necrosis, Metastasis
- B. Tumor, Node Involvement, Mastectomy
- C. Tumor, Node Involvement, Metastasis
- D. Therapy, Necrosis, Metastasis
Correct Answer: B
Rationale: The TNM staging system is a classification system for determining the size and extent of cancerous tissue. The TNM system helps providers to identify the most accurate forms of treatment. The T stands for tumor, the N stands for node involvement, and the M stands for metastasis. Choice A, 'Tumor, Necrosis, Metastasis,' is incorrect because it does not include the node involvement component. Choice B, 'Tumor, Node Involvement, Mastectomy,' is incorrect as it erroneously includes the treatment approach 'Mastectomy' instead of 'Metastasis.' Choice D, 'Therapy, Necrosis, Metastasis,' is incorrect because it includes 'Therapy' instead of the correct component 'Node Involvement.'
A 45-year-old woman is prescribed ropinirole (Requip) for Parkinson's Disease. The patient is living at home with her daughter. The nurse is most concerned about which side effect of ropinirole?
- A. Slurred speech
- B. Sudden dizziness
- C. Mask-like facial expression
- D. Stooped posture
Correct Answer: B
Rationale: The correct answer is 'Sudden dizziness.' Dizziness and orthostatic hypotension are serious adverse effects of ropinirole that can lead to an increased risk of falls. Ropinirole belongs to the drug class of dopamine agonists, which mimic dopamine in the brain (Parkinson's Disease is characterized by a lack of dopamine). 'Slurred speech' is not a common side effect of ropinirole. 'Mask-like facial expression' and 'Stooped posture' are more associated with the progression of Parkinson's Disease itself rather than a side effect of ropinirole.
The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis?
- A. His pediatrician said his kidneys are working well.''
- B. I noticed his urine was the color of cola lately.''
- C. I'm so glad they didn't find any protein in his urine.''
- D. The nurse who admitted my child said his blood pressure was low.''
Correct Answer: B
Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored, or brown-colored urine, is a classic symptom of glomerulonephritis. Blood urea nitrogen levels and serum creatinine levels may be elevated, indicating that kidney function is compromised. A mild to moderate elevation in protein in the urine is associated with glomerulonephritis. Hypertension is also common because of fluid volume overload secondary to the kidneys not working properly. Therefore, the parent's statement about noticing cola-colored urine aligns with the expected symptom in glomerulonephritis. The other options are less indicative of glomerulonephritis: choice A indicates normal kidney function, choice C mentions absence of protein in the urine (which is not expected in glomerulonephritis), and choice D talks about low blood pressure (hypertension is more common in glomerulonephritis).