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A client with lung cancer develops Homer’s when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:
- A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
- B. Chest pain, dyspnea, cough, weight loss, and fever.
- C. Arm and shoulder pain and atrophy of arm and hand muscles both on the affected side.
- D. Hoarseness and dysphagia.
Correct Answer: A
Rationale: The correct answer is A: Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. This is indicative of Horner's syndrome, which occurs due to the disruption of sympathetic nerve supply. Miosis (constricted pupil), ptosis (drooping eyelid), and anhidrosis (lack of sweating) are classic signs of Horner's syndrome. These symptoms occur when the tumor invades the ribs and affects the sympathetic nerve ganglia.
Summary of other choices:
B: Chest pain, dyspnea, cough, weight loss, and fever are more commonly associated with lung cancer but not specific to Horner's syndrome.
C: Arm and shoulder pain and atrophy of arm and hand muscles are not typical signs of Horner's syndrome.
D: Hoarseness and dysphagia are more common symptoms of compression of the recurrent laryngeal nerve, not Horner's syndrome.
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The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?
- A. Cognitive
- B. Interpersonal
- C. Psychomotor
- D. Judgmental
Correct Answer: C
Rationale: The correct answer is C: Psychomotor. The nurse is demonstrating psychomotor skills by inserting an IV catheter correctly. Psychomotor skills involve the ability to perform physical tasks effectively and efficiently. This skill requires coordination, dexterity, and precision. The other choices are incorrect because:
A: Cognitive skills involve thinking, analyzing, and problem-solving.
B: Interpersonal skills involve communication and interaction with others.
D: Judgmental skills involve critical thinking and decision-making.
Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?
- A. carbon dioxide level
- B. prothrombin time
- C. gastric pH
- D. white blood cell count
Correct Answer: B
Rationale: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is because the patient's non-verbal cues (facial grimacing) are contradicting their verbal report of low pain level. By asking the patient directly, the nurse can clarify the discrepancy and gain a better understanding of the patient's actual pain level and needs.
Choice A is incorrect as it disregards the patient's observed discomfort. Choice B assumes the patient does not want pain medicine without clarifying the situation first. Choice D is premature as administering pain medication without further assessment may not be appropriate or safe.
In summary, asking the patient about the facial grimacing is essential to ensure accurate pain assessment and appropriate intervention.
A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?
- A. Health status NursingStoreRN
- B. Health behavior
- C. Psychological self-control
- D. Health service utilization
Correct Answer: B
Rationale: The correct answer is B: Health behavior. Evaluating the patient's demonstration of self-injection assesses their ability to perform a specific health-related action. This choice focuses on the patient's actions and behaviors related to their health, aligning with the scenario provided.
Choice A: Health status is incorrect because it refers to the patient's current physical condition, not their ability to perform a specific health action.
Choice C: Psychological self-control is incorrect as it pertains to the patient's ability to regulate their emotions and impulses, not their ability to self-administer injections.
Choice D: Health service utilization is incorrect as it relates to the frequency and pattern of healthcare services used by the patient, not their ability to perform a specific health behavior.
Following the American Cancer Society guidelines, the nurse should recommend that the women:
- A. Perform breast self-examination annually
- B. Have a mammogram annually
- C. Have a normal receptor assay annually
- D. Have a physician conduct a clinical examination every 2 years
Correct Answer: B
Rationale: The correct answer is B: Have a mammogram annually. Mammograms are recommended by the American Cancer Society for breast cancer screening in women as they are effective in detecting early signs of breast cancer. Mammograms have been shown to reduce mortality rates from breast cancer. Annual mammograms are crucial for early detection and treatment.
A: Performing breast self-examination annually is not recommended as a standalone screening method as it has not been shown to significantly reduce mortality rates.
C: Having a normal receptor assay annually is not a standard screening test for breast cancer recommended by the American Cancer Society.
D: Having a physician conduct a clinical examination every 2 years is not as effective as annual mammograms for detecting early signs of breast cancer.