Nokea
A client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect:
- A. Hair loss.
- B. Fatigue.
- C. Stomatitis.
- D. Vomiting.
Correct Answer: A
Rationale: Radiation therapy works by targeting rapidly dividing cells in the body, which includes not only cancer cells but also healthy cells. Hair loss, also known as alopecia, is a common side effect of radiation therapy because the hair follicles are fast-growing cells that can be affected by the radiation. The extent of hair loss can vary depending on the dose and area of the body being treated. It is essential for nurses to prepare clients for the possibility of hair loss during radiation therapy and provide support and information on managing this side effect.
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A newborn is diagnosed with retinopathy of prematurity. What should the nurse know about this diagnosis?
- A. Blindness cannot be prevented.
- B. No treatment is currently available.
- C. Cryotherapy and laser therapy are effective treatments.
- D. Long-term administration of oxygen will be necessary.
Correct Answer: C
Rationale: Retinopathy of prematurity (ROP) is a disorder of the developing retinal blood vessels in premature infants. Cryotherapy and laser therapy are both effective treatments for ROP. These treatments can help prevent vision loss and improve the chances of maintaining good vision. Prompt detection and intervention are key in managing ROP to prevent long-term visual impairment. Therefore, the nurse should be aware that cryotherapy and laser therapy are effective interventions for ROP, contrary to the options suggesting blindness cannot be prevented or no treatment is available. Long-term administration of oxygen can contribute to the development of ROP, so careful monitoring and management of oxygen levels are necessary in premature infants to prevent this condition.
Because of the significant association of lead intoxication with poverty, the Centers for Disease Control and Prevention (CDC) recommends blood lead screening at
- A. 6 and 12 months
- B. 12 and 24 months
- C. 24 and 36 months
- D. 36 and 48 months
Correct Answer: B
Rationale: Blood lead screening is recommended at 12 and 24 months.
The adolescent patient has symptoms of meningitis: nuchal rigidity, fever, vomiting, and lethargy. The nurse knows to prepare for the following test:
- A. blood culture.
- B. throat and ear culture.
- C. CAT scan.
- D. lumbar puncture.
Correct Answer: D
Rationale: The symptoms described (nuchal rigidity, fever, vomiting, and lethargy) suggest possible meningitis, which is an inflammation of the meninges, the membranes surrounding the brain and spinal cord. One of the key diagnostic tests for meningitis is a lumbar puncture, also known as a spinal tap. During a lumbar puncture, cerebrospinal fluid (CSF) is collected from the space around the spinal cord and analyzed for signs of infection, inflammation, or other abnormalities. This test helps confirm or rule out a diagnosis of meningitis and identify the specific infectious agent causing the illness. Other tests, such as blood cultures, may also be done to further evaluate the infection, but a lumbar puncture is essential for diagnosing meningitis in this case.
When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. How should the nurse assess this diet?
- A. Indicates they live in poverty
- B. Is lacking in protein
- C. May provide sufficient amino acids
- D. Should be enriched with meat and milk
Correct Answer: C
Rationale: The nurse should assess that the diet of the Hispanic family, which consists mainly of vegetables, legumes, and starches, may provide sufficient amino acids. While this diet may lack animal sources of protein commonly found in meat and milk, plant-based foods like legumes and grains can complement each other to provide all essential amino acids necessary for protein synthesis in the body. This combination of foods essentially forms a complete protein source, supporting overall nutritional needs. It's important for the nurse to recognize the potential nutritional value in the diet and offer education on balanced meal planning to ensure adequate protein intake for the family. The assessment should focus on the overall nutrient adequacy and not solely on the presence of specific food items.
The least common late neurologic sequelae that may be encountered post craniospinal irradiation in a 9-year-old child with medulloblastoma is
- A. microcephaly
- B. learning disabilities
- C. cognitive impairment
- D. second malignancy
Correct Answer: D
Rationale: Second malignancy is a rare late effect compared to cognitive and learning impairments.