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A hospitalized client has a platelet count of 58,000/mm³. What action by the nurse is best?
- A. Implement fall precautions
- B. Encourage high-protein foods
- C. Limit visitors to healthy adults
- D. Institute neutropenic precautions
Correct Answer: A
Rationale: A platelet count of 58,000/mm³ below 150,000 signals thrombocytopenia, raising bleeding risk, especially from falls. Implementing fall precautions curbs trauma, preventing bleeds like intracranial hemorrhage, a practical priority over dietary tweaks. High-protein foods aid healing but don't address immediate danger. Limiting visitors or neutropenic precautions fits low WBCs, not platelets 58,000 isn't neutropenic (below 1,000 neutrophils). Nurses prioritize safety, making fall precautions the best action, directly mitigating this lab's implications in a hospitalized client prone to injury.
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The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer?
- A. Teach the patient about the seven warning signs of cancer.
- B. Plan to monitor the patient's carcinoembryonic antigen (CEA) level.
- C. Teach the patient about annual chest x-rays for lung cancer screening.
- D. Discuss risks associated with cigarette smoking during each patient encounter.
Correct Answer: D
Rationale: Smoking's the lung cancer kingpin two packs a day screams risk. Hitting the patient with smoking's dangers every visit pushes primary prevention, aiming to cut exposure to tar and carcinogens fueling 85% of cases. Warning signs (CAUTION) and chest x-rays are secondary catching cancer, not stopping it. CEA's a tumor marker for tracking, not prevention. Nurses in oncology know preaching cessation at every chance leverages behavior change, the gold standard to slash lung cancer odds, trumping screening or monitoring in a heavy smoker like this.
The nurse is preparing an adolescent diagnosed with leukemia for a lumbar puncture. The nurse determines that the child understands the reason for the procedure when the child states that the procedure is done to:
- A. Make sure I don't have meningitis along with my cancer.
- B. Relieve some of the pressure on my brain.
- C. Remove the blood cancer cells so I don't have to have surgery.
- D. Check to see if the cancer has spread through my spinal cord and brain.
Correct Answer: D
Rationale: A lumbar puncture (LP) in leukemia is performed to collect cerebrospinal fluid (CSF) to check for central nervous system (CNS) involvement cancer cells spreading to the spinal cord and brain a critical staging step that influences treatment, like intrathecal chemotherapy. The adolescent's statement about checking for spread reflects accurate understanding, essential for informed consent and reducing anxiety through clarity. Ruling out meningitis is a possible LP use, but in leukemia, CNS metastasis is the primary concern unless symptoms suggest infection. Relieving brain pressure applies to conditions like hydrocephalus, not leukemia's typical presentation. Removing cancer cells via LP isn't a treatment; it's diagnostic. The nurse's confirmation of this understanding ensures the child is prepared, aligning with pediatric oncology's emphasis on patient education and procedural readiness.
What is the essence of motivational interviewing?
- A. That change strategies must exactly match the patient's motivation
- B. That behavioural change is impossible if the patient does not want it
- C. That the counsellor motivates the patient to change and increases patient involvement
- D. That the patient's motives to show unhealthy behaviour are systematically analysed
Correct Answer: C
Rationale: Motivational interviewing counsellor sparks, pulls patients in, not rigid matches, impossibles, or motive digs. Nurses roll this, a chronic engagement art.
Which of the following is NOT an example of intermittent fasting?
- A. Alternate day fasting
- B. Mediterranean dieting
- C. Modified fasting regimes such as the 5:2 diet'
- D. Time restricted feeding
Correct Answer: B
Rationale: Fasting flips alternate, 5:2, timed, holy skips; Mediterranean's steady, not starved. Nurses clock this chronic fast gap.
A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose?
- A. 0.25
- B. 0.5
- C. 1
- D. 1.5
Correct Answer: B
Rationale: Digoxin math: 125 mcg ordered, 0.25 mg (250 mcg) per tablet 125 ÷ 250 = 0.5 tablets, a precise dose nurses calc to boost heart failure's pump, avoiding toxicity's narrow edge. Wrong cuts (0.25, 1, 1.5) miss the mark. Accuracy here rules, a daily win in this med game.