Nokea
A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:
- A. Receive monthly blood transfusions
- B. Increase the amount of iron in her diet
- C. Eat small quantities several times daily until she is able to tolerate food in moderate portions
- D. Understand the need for Vitamin B12 replacement therapy
Correct Answer: D
Rationale: Monthly blood transfusions are not indicated postgastrectomy. Increasing iron in the client's diet may cause irritation and will not alleviate pernicious anemia. It may be necessary that the client eat small meals several times per day, but this measure has no relevance to prevention of pernicious anemia. Pernicious anemia is caused by lack of Vitamin B12, and replacement therapy will be necessary because the client's stomach has been removed.
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On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
- A. Xerostomia
- B. Candidiasis
- C. Leukoplakia
- D. Stomatitis
Correct Answer: C
Rationale: Leukoplakia cannot be rubbed off.
While reading the progress notes on a client with cancer, the nurse notes a TNM classification of T1, N1, M0. What does this classification indicate?
- A. The tumor is in situ, no regional lymph nodes are involved, and there is no metastasis.
- B. No evidence of primary tumor exists, lymph nodes can't be assessed, and metastasis can't be assessed.
- C. The tumor is extended, with regional lymph node involvement and distant metastasis.
- D. The tumor is extended and regional lymph nodes are involved, but there is no metastasis.
Correct Answer: D
Rationale: T1 indicates a small tumor, N1 indicates regional lymph node involvement, and M0 indicates no distant metastasis. Option A is incorrect (T1 is not in situ), B is incorrect (T0, not T1, means no tumor), and C is incorrect (M0 means no metastasis).
The nurse is assessing a client who had a colon resection two days ago. The client states, "I feel like my stitches have burst loose." Upon further assessment, dehiscence of the wound is noted. Which action should the nurse take?
- A. Immediately place the client in the prone position.
- B. Apply a sterile, saline-moistened dressing to the wound.
- C. Administer atropine to decrease abdominal secretions.
- D. Wrap the abdomen with an ACE bandage.
Correct Answer: B
Rationale: Applying a sterile, saline-moistened dressing protects the dehisced wound and prevents infection. Prone positioning (A) is inappropriate, atropine (C) doesn’t address dehiscence, and an ACE bandage (D) may worsen the condition.
The client is prescribed methotrexate for rheumatoid arthritis. Which instruction should the nurse include?
- A. Take the medication with milk to prevent stomach upset.'
- B. Report any signs of infection immediately.'
- C. Avoid exposure to sunlight.'
- D. Take the medication only when joint pain is severe.'
Correct Answer: B
Rationale: Methotrexate causes immunosuppression, increasing infection risk, so reporting signs of infection is critical. Milk does not prevent GI upset, photosensitivity is not a primary concern, and methotrexate is taken regularly, not as needed.
The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son's condition by which of the following statements?
- A. Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain.'
- B. Has anyone in your family ever had schizophrenia?'
- C. If your son has a twin, he probably will eventually develop schizophrenia, too.'
- D. Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship.'
Correct Answer: A
Rationale: The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms.