Nokea
A nurse is caring for a client with a history of an abdominal aortic aneurysm. Which of the following assessment findings requires immediate intervention?
- A. Back pain
- B. Absent peripheral pulses
- C. Decreased urine output
- D. Nausea and vomiting
Correct Answer: B
Rationale: An AAA can rupture absent peripheral pulses signal dissection or clot, cutting flow, a surgical emergency needing instant action per ABCs. Back pain hints at expansion, urgent but less acute. Urine drop or nausea follows, not leads. Nurses jump on pulselessness, anticipating OR prep, a life-or-limb save in this ticking vascular bomb.
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Chemotherapeutic treatment of acute leukemia is done in four phases. Place these phases in the correct order.
- A. Maintenance
- B. Induction
- C. Intensification
- D. Consolidation
Correct Answer: B
Rationale: Acute leukemia's chemotherapy unfolds systematically: induction kicks off, aggressively killing leukemia cells to induce remission, a high-dose blitz. Intensification follows, targeting residual cells over months, relentless in early remission. Consolidation reinforces, eliminating lingering blasts post-remission, solidifying gains. Maintenance, with lower doses, sustains remission long-term, preventing relapse. This order induction, intensification, consolidation, maintenance mirrors the disease's need for initial eradication then sustained control, a structured approach nurses reinforce through patient education and monitoring, ensuring each phase's purpose aligns with leukemia's aggressive biology and treatment goals.
The nurse is caring for a 55-year-old male who presented to this primary physician's office for his yearly check-up. Upon the physical assessment, the provider noted enlarged lymph nodes in the groin and neck region. The provider Questioned Joe regarding the possible causes of the finding. Which of the following diagnosis are consistent with this finding?
- A. Leukemia
- B. Lymphoma
- C. Sickle cell anemia
- D. Polycythemia vera
Correct Answer: B
Rationale: Lymphoma swells nodes neck and groin lumps fit this cancer's lymphoid sprawl, a diagnosis matching this check-up find. Leukemia bones out, sickle cell pains, polycythemia thickens none node-centric. Nurses tie this to lymphoma, anticipating biopsy, a nodal tale in this cancer hunt.
As per Johnson and Chang (2014) which of the following is not a component of the Chronic Care Model?
- A. Person centred care
- B. Population health approach
- C. Community setting, collaborative across both primary and secondary care
- D. Reactive, symptom driven
Correct Answer: D
Rationale: The Chronic Care Model thrives on proactive pillars person-centered focus, population health, and community-primary-secondary teamwork aiming to preempt, not just patch, chronic woes. Reactive, symptom-driven care's old-school, clashing with this forward lean. Nurses ditch that lag, embracing prevention, a model shift for chronic mastery.
Which of the following statements is INCORRECT? The treatment of diabetes in traditional Chinese medicine involves
- A. Formula for Diabetes (Xiaoke Fang) for the Upper Type: Heat in the Lung which consumes Body Fluid
- B. Jade Maid Decoction (Yunu Jiang) for the Middle Type: excessive Heat in the Stomach
- C. Six Ingredients Rehmannia Pill (Liuwei Dihuang Wan) for the Lower Type: excessive of Kidney Yin and excessive of Yin and Yang
- D. Yam (Dioscorea opposita)
Correct Answer: C
Rationale: Traditional Chinese diabetes care Upper, Middle, Lower types nails Lung heat, Stomach fire, but Kidney's Yin deficiency, not excess Yin-Yang, flops. Xiaoke Fang, Yunu Jiang fit; Liuwei Dihuang Wan balances, doesn't overdo; yam's a lone root, not typed. Clinicians spot this, a chronic TCM misstep.
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as the priority in the client's care?
- A. Ineffective peripheral tissue perfusion
- B. Alteration in body image
- C. Impaired skin integrity
- D. Alteration in activity tolerance
Correct Answer: C
Rationale: Varicose veins with ulcerations, edema, and heaviness scream venous stasis impaired skin integrity tops the list as open sores risk infection, a pressing threat needing immediate wound care. Ineffective perfusion drives the issue, but skin breakdown's acuity trumps. Body image matters emotionally, less urgently. Activity tolerance lags behind active complications. Nurses prioritize skin integrity, addressing ulcers' vulnerability, a direct care focus to halt deterioration in this chronic venous picture, aligning with safety and healing goals.