Nokea
A client with advanced liver cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to prescribe:
- A. Fluoxymesterone (Halotestin)
- B. Fluorouracil (5-fluorouracil, 5 FU
- C. Tamoxifen (Nolvadex) [Fluoroplex])
- D. Megestrol (Megace)
Correct Answer: B
Rationale: Fluorouracil (5-FU) is a commonly used chemotherapy drug for various cancers, including of the liver. It is often used to treat advanced liver cancer as part of a chemotherapy regimen. 5-FU works by interfering with the synthesis of DNA and RNA in cancer cells, leading to their death.
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Discharge care planning has begun for a seriously injured patient who is Asian. The patient's parents have refused routine home health visits. The pediatric nurse understands the family may:
- A. believe that health outcomes are predetermined.
- B. feel health is a personal responsibility and maintenance of family reputation is paramount.
- C. regard health as a family responsibility, seeking outside aid only when resources are exhausted.
- D. none of the above.
Correct Answer: C
Rationale: In some cultures, families may prefer to handle health matters internally, viewing outside assistance as a last resort.
Increased intracranial pressure can cause which of the following?
- A. seizure
- B. nausea
- C. vomiting
- D. all of the above
Correct Answer: D
Rationale: Increased intracranial pressure (ICP) can cause a variety of symptoms, including seizures, nausea, and vomiting. When the pressure inside the skull rises, it can put pressure on the brain tissue, leading to changes in normal brain function. Seizures may occur as a result of the altered brain activity. Nausea and vomiting can also be triggered by increased ICP, as the body's natural response to the disturbance in the brain's normal functioning. Therefore, all of the listed options (seizure, nausea, vomiting) can be caused by increased intracranial pressure.
Hepatitis C virus infection is a risk factor for which of the following malignancy?
- A. hepatoblastoma
- B. splenic lymphoma
- C. Hodgkin lymphoma
- D. nasopharyngeal carcinoma
Correct Answer: B
Rationale: Hepatitis C is a known risk factor for splenic lymphoma and other B-cell lymphoproliferative disorders.
The nurse is preparing a parent of a newborn for home phototherapy. Which statement made by the parent would indicate a need for further teaching?
- A. "I should change the baby's position many times during the day."
- B. "I can dress the baby in lightweight clothing while under phototherapy."
- C. "I should be sure that the baby's eyelids are closed before applying patches."
- D. "I can take the patches off the baby during feedings and other caregiving activities."
Correct Answer: D
Rationale: The correct statement should be that the patches need to remain on the baby's eyes at all times during phototherapy. Removing the eye patches can potentially allow harmful light exposure to the eyes, which can lead to complications such as eye damage. It is essential for the parent to understand the importance of keeping the eye patches on to protect the baby's eyes during phototherapy. Therefore, further teaching is needed to emphasize the importance of leaving the eye patches on at all times, even during feedings and caregiving activities.
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
- A. Obtain vita! Signs
- B. Assess the pain further
- C. Stop the transfusion
- D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C
Rationale: Lumbar pain during a blood transfusion can be a sign of an adverse reaction, such as a transfusion reaction. Any complaints of pain during a transfusion should not be ignored. In this case, the nurse should first stop the transfusion to prevent any further complications. The client should be assessed promptly for other signs of a transfusion reaction, and appropriate actions should be taken as needed to ensure the client's safety and well-being.