Nokea
A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history?
- A. History of breast cancer
- B. History of hypertension
- C. History of diabetes
- D. History of osteoarthritis
Correct Answer: A
Rationale: The correct answer is A: History of breast cancer. Menopausal hormone therapy (HT) is contraindicated in women with a history of breast cancer due to the potential risk of hormone-dependent cancer recurrence. Hormones can stimulate the growth of estrogen-sensitive breast cancer cells, increasing the risk of cancer recurrence. Therefore, it is crucial for the nurse to inform the client with a history of breast cancer that HT is not recommended. Choices B, C, and D are not directly contraindications for HT in menopausal clients, as long as these conditions are well-controlled and monitored.
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A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
- A. Basal cell carcinoma has a low incidence of metastasis.
- B. Basal cell carcinoma is often fatal.
- C. Basal cell carcinoma metastasizes early.
- D. Basal cell carcinoma is more common in younger clients.
Correct Answer: A
Rationale: The correct answer is A: Basal cell carcinoma has a low incidence of metastasis. Basal cell carcinoma rarely metastasizes to other parts of the body, making it highly curable through surgical excision. This information is crucial for patients to understand the low likelihood of the cancer spreading. Choices B and C are incorrect because basal cell carcinoma is not typically fatal nor does it metastasize early. Choice D is incorrect as basal cell carcinoma is more common in older adults, not younger clients.
A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching?
- A. I will eat food that are served at room temperature.
- B. I will eat food that is very hot.
- C. I will drink large amounts of fluids with meals.
- D. I will eat a large meal right before chemotherapy.
Correct Answer: A
Rationale: Correct Answer: A: "I will eat food that is served at room temperature."
Rationale: Eating foods at room temperature can help decrease nausea because hot foods may worsen nausea, while cold foods could cause stomach discomfort. Room temperature foods are generally easier on the stomach and may be better tolerated during chemotherapy and radiation. This choice demonstrates an understanding of how food temperature can impact nausea.
Summary of other choices:
B: Eating very hot food can actually worsen nausea.
C: Drinking large amounts of fluids with meals can dilute stomach acid and enzymes, potentially worsening nausea.
D: Eating a large meal right before chemotherapy can lead to increased nausea and discomfort.
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
- A. Atropine
- B. Epinephrine
- C. Magnesium
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Rationale: Atropine is the correct answer because it is the first-line medication for symptomatic bradycardia. It works by blocking the parasympathetic nervous system, increasing heart rate. Epinephrine is used for cardiac arrest, not bradycardia. Magnesium is for torsades de pointes, not bradycardia. Sodium bicarbonate is for metabolic acidosis, not bradycardia.
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
- A. Defibrillation
- B. Administer oxygen
- C. Call for help
- D. Start chest compressions
Correct Answer: A
Rationale: The correct answer is A: Defibrillation. Ventricular fibrillation is a life-threatening arrhythmia that requires immediate defibrillation to restore the heart's normal rhythm. Defibrillation is the priority as it is the most effective intervention to treat ventricular fibrillation and increase the chance of survival. Administering oxygen (B) is important but not the priority over defibrillation. Calling for help (C) should be done after initiating defibrillation. Starting chest compressions (D) should only be done if defibrillation is not immediately available or unsuccessful.
A nurse assesses a client in skeletal traction. What indicates infection at the pin sites?
- A. Pallor
- B. Fever
- C. Bradycardia
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Fever. Infection at the pin sites in skeletal traction commonly presents with systemic signs like fever. Fever is a typical response to infection as the body tries to fight off the invading pathogens. Pallor, bradycardia, and elevated blood pressure are not specific indicators of infection at pin sites. Pallor may indicate poor perfusion, bradycardia is a slow heart rate which is not typically associated with infection, and elevated blood pressure can be a response to various stressors but not a specific sign of infection at pin sites. In summary, fever is the most reliable indicator of infection at pin sites due to its systemic nature.