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A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
- A. Establish the ability to communicate effectively.
- B. Increase mobility on the affected side.
- C. Increase independence in activities of daily living.
- D. Prevent falls during rehabilitation.
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. Communication is a key aspect affected by left hemispheric CVA, which can lead to aphasia or difficulty in speaking and understanding language. By prioritizing communication goals, the nurse can enhance the client's quality of life, facilitate social interactions, and improve overall rehabilitation outcomes. Increasing mobility (B) and independence in activities of daily living (C) are important but may not directly address the communication deficits. Preventing falls (D) is also crucial but not specific to the client's primary deficit.
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A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care?
- A. I should expect the hospice team to help me manage my dyspnea.
- B. I will receive chemotherapy to treat my cancer.
- C. I will be admitted to the hospital for further treatment.
- D. I will receive radiation therapy to shrink the tumor.
Correct Answer: A
Rationale: Correct Answer: A - "I should expect the hospice team to help me manage my dyspnea."
Rationale: Hospice care focuses on providing comfort and quality of life for patients with terminal illnesses, such as advanced lung cancer. Dyspnea (difficulty breathing) is a common symptom in lung cancer patients, and the hospice team is trained to provide symptom management and relief. By acknowledging the role of the hospice team in managing dyspnea, the client demonstrates an understanding of the palliative nature of hospice care.
Summary of other choices:
B: "I will receive chemotherapy to treat my cancer." - Hospice care does not aim to cure the underlying illness but rather focuses on comfort and quality of life.
C: "I will be admitted to the hospital for further treatment." - Hospice care is typically provided in the comfort of the patient's own home or a hospice facility, not in a hospital setting for further treatment.
D: "I will receive radiation therapy
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?
- A. Electrocardiogram
- B. Chest X-ray
- C. Echocardiogram
- D. MRI of the chest
Correct Answer: D
Rationale: The correct answer is D. MRI of the chest should be clarified because the magnetic field can interfere with the function of the pacemaker, potentially causing harm to the patient. An electrocardiogram, chest X-ray, and echocardiogram are safe imaging tests that do not interfere with the pacemaker. Therefore, D is the correct answer that should be clarified to ensure patient safety.
A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?
- A. Artificial lubrication can be used to treat vaginal itching and dryness.
- B. Avoid sexual activity for the first 6 months.
- C. Use a menstrual pad for vaginal bleeding.
- D. Use a diaphragm for contraception.
Correct Answer: A
Rationale: The correct answer is A: Artificial lubrication can be used to treat vaginal itching and dryness. The rationale for this is that after a total abdominal hysterectomy and bilateral salpingo-oophorectomy, there is a decrease in estrogen levels, leading to vaginal dryness and itching. Using artificial lubrication can help alleviate these symptoms and improve comfort.
Choice B is incorrect as there is no need to avoid sexual activity for 6 months unless specifically advised by the healthcare provider. Choice C is incorrect as there should not be vaginal bleeding after a total abdominal hysterectomy. Choice D is incorrect as using a diaphragm for contraception is not recommended after a hysterectomy.
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?
- A. Creatinine
- B. Bilirubin
- C. Amylase
- D. Albumin
Correct Answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, there is inflammation of the pancreas leading to leakage of pancreatic enzymes like amylase into the blood. Elevated amylase levels are a hallmark of acute pancreatitis. Creatinine (A) is related to kidney function, bilirubin (B) to liver function, and albumin (D) to protein status. In acute pancreatitis, the focus is on pancreatic enzymes like amylase.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Visitors from outside the hospital
- C. Foods high in vitamin C
- D. A humidifier in the room
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and potted plants can harbor bacteria and fungi, increasing the risk of infection. Restricting these items helps minimize exposure to pathogens. Choices B and D are incorrect as long as visitors are screened for infections and the humidifier is cleaned regularly. Choice C, foods high in vitamin C, is incorrect as these foods can actually help boost the immune system.