Nokea
A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior is probably caused by:
- A. Uncertainty and an underlying fear of recurrence.
- B. The usual trajectory of a short-term illness.
- C. A history of a behavioral illness.
- D. The one-time crisis from learning of the diagnosis.
Correct Answer: A
Rationale: Disruptive behavior in a cancer client is often driven by uncertainty and fear of recurrence, reflecting ongoing emotional distress.
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The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis?
- A. Avoid the use of caffeinated beverages.
- B. Perform postural drainage every day.
- C. Take hot showers twice daily.
- D. Report a temperature of 102°F (38.9°C) or higher.
Correct Answer: C,D
Rationale: Hot showers help moisten nasal passages and promote sinus drainage, relieving symptoms of chronic sinusitis. Reporting a high fever is critical as it may indicate a worsening infection requiring medical attention. Caffeine restriction is not typically necessary. Postural drainage is more relevant for lung conditions like bronchiectasis.
A client with thyrotoxicosis says to the nurse, 'I am so irritable. I am having problems at work because I lose my temper very easily.' Which of the following responses by the nurse would give the client the most accurate explanation of her behavior?
- A. Your behavior is caused by your not following the medical regimen.'
- B. Your behavior is caused by the effects of the disease on your thyroid.'
- C. Your behavior is caused by your not accepting your diagnosis.'
- D. Your behavior is caused by the effects of the disease on your emotional stability.'
Correct Answer: B
Rationale: Thyrotoxicosis, due to excess thyroid hormone, increases metabolism and can affect the nervous system, leading to irritability and emotional lability. This explains the client's behavior as a direct result of the disease's impact on thyroid function.
The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?
- A. Tay-Sachs cells.
- B. Reed-Sternberg cells.
- C. Duchenne's cells.
- D. None of the above
Correct Answer: B
Rationale: Hodgkin's disease is diagnosed by the presence of Reed-Sternberg cells, large multinucleated cells, in the lymph node biopsy. Tay-Sachs and Duchenne's cells are unrelated to Hodgkin's.
A priority nursing diagnosis for an adult female who has pruritus and is continuously scratching the affected areas and demonstrates agitation and anxiety regarding the itching sensation would be:
- A. Risk for infection related to pruritus.
- B. Ineffective health maintenance related to lack of knowledge of the disease process.
- C. Unsporced skin integrity related to dehydration from the treatment medications.
- D. Social isolation related to poor self-image.
Correct Answer: A
Rationale: Scratching due to pruritus increases the risk of skin breakdown and infection, making this the priority nursing diagnosis.
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?
- A. Limit fluid intake to 1,000 mL/day.
- B. Insert an indwelling urinary catheter.
- C. Establish a regular voiding schedule.
- D. Administer prophylactic antibiotics, as ordered.
Correct Answer: C
Rationale: A regular voiding schedule helps manage incontinence by promoting bladder emptying before urgency. Fluid restriction risks dehydration, indwelling catheters increase infection risk, and antibiotics are not preventive for incontinence.