Nokea
A client with throat cancer receives radiation therapy to the head and neck. Which of the following strategies are appropriate to decrease the adverse effects associated with radiation therapy? Select all that apply.
- A. Avoid irritants such as acidic, spicy foods
- B. Discourage the use of topical analgesics
- C. Encourage liquid nutritional supplements
- D. Perform oral hygiene once per day
- E. Use artificial saliva to control dryness
Correct Answer: A,C,E
Rationale: Avoiding irritants reduces mucosal irritation. Liquid supplements ensure adequate nutrition when swallowing is difficult. E: Artificial saliva alleviates xerostomia, a common side effect. B is incorrect as topical analgesics may be beneficial for pain relief. D is incorrect as frequent oral hygiene is needed to prevent infections and maintain oral health.
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The nurse is evaluating the security of the client's tracheostomy ties. Which of the following methods is used to assess for tie tightness?
- A. The nurse places one finger between the tie and the neck.
- B. The tracheostomy can be pulled slightly away from the neck.
- C. There are no tie marks present.
- D. The nurse uses a Velcro fastener instead of a tie.
Correct Answer: A
Rationale: Placing one finger between the tie and neck ensures ties are secure but not overly tight, preventing tissue damage or airway obstruction.
The physician has ordered a minimal bacteria diet on a client with neutropenia. Which seasoning is not permitted for this client?
- A. Salt
- B. Lemon juice
- C. Pepper
- D. Ketchup
Correct Answer: C
Rationale: A minimal bacteria diet for neutropenic clients avoids foods that may harbor bacteria, such as raw or undercooked foods and certain seasonings like pepper, which can contain mold or bacteria. Salt , lemon juice , and ketchup are generally processed and less likely to pose a bacterial risk.
At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates
- A. Feelings of increasing anxiety related to paranoia
- B. Social isolation related to altered thought processes
- C. Sensory perceptual alteration related to withdrawal from environment
- D. Impaired verbal communication related to impaired judgment
Correct Answer: B
Rationale: Social isolation related to altered thought processes. Hostility and lack of engagement suggest isolation driven by paranoid thoughts.
A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following instructions would be best for the nurse to tell the caregiver?
- A. Increase bladder tone by delaying voiding
- B. When laundering clothing, rinse several times
- C. Use plain water for the bath, shampooing hair last
- D. Have the child use antibacterial soaps while bathing
Correct Answer: C
Rationale: Use plain water for the bath, shampooing hair last. Hair should be shampooed last with a rinsing of plain water over the genital area. The oils in soaps and bubble bath can cause irritation, which may lead to UTIs in young girls.
The emergency department nurse is caring for a 70-year-old client with a history of type 2 diabetes mellitus who reports sudden-onset nausea, sweating, dizziness, and fatigue. The nurse should anticipate the initiation of which protocol?
- A. Food poisoning
- B. Influenza
- C. Myocardial infarction
- D. Stroke
Correct Answer: C
Rationale: Symptoms like nausea, sweating, dizziness, and fatigue in a 70-year-old with diabetes suggest myocardial infarction, requiring immediate cardiac protocol initiation.