Nokea
A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?
- A. Discomfort while changing position
- B. Reports pain as a 7 on a 0 to 10 scale
- C. Disruption of tissue integrity
- D. Dull headache
Correct Answer: C
Rationale: The correct answer is C: Disruption of tissue integrity. Acute pain is typically caused by tissue damage or injury, such as a cut or a burn. The nurse would use this assessment data as an etiology for acute pain because it directly relates to the source of the pain. Discomfort while changing position (A) is a symptom of pain but does not provide the underlying cause. Reports pain as a 7 on a 0 to 10 scale (B) is a pain intensity rating and does not explain the cause of the pain. Dull headache (D) is a specific type of pain but is not relevant to the given scenario of tissue disruption.
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Which of the ff. positions is best for a chest drainage system when the patient is being transported by wheelchair?
- A. Hang it on the top of the wheelchair backrest.
- B. Place it on the patient’s feet and ask the patient to hold it.
- C. Hang it on the same pole as the patient’s IV.
- D. Place it in the patient’s lap.
Correct Answer: A
Rationale: The correct answer is A because hanging the chest drainage system on the top of the wheelchair backrest ensures that the system remains upright and secured during transportation, reducing the risk of accidental disconnection or leakage. Placing it on the patient's feet (B), hanging it with the IV pole (C), or placing it in the patient's lap (D) can lead to potential complications such as pulling or kinking the drainage tubing, increasing the risk of infection or injury to the patient.
60 year-old Mrs. Torres arrived just in time for her doctor’s appointment. She complains of pain and stiffness in her back. She is suspected of having osteoporosis. Nurse Ariane will inform Mrs. Torres that the primary complication of osteoporosis is:
- A. Increased trabeculae
- B. poor posture
- C. chronic pain
- D. fractures
Correct Answer: D
Rationale: The correct answer is D: fractures. Osteoporosis weakens bones, making them more prone to fractures. Fractures are the primary complication of osteoporosis due to decreased bone density. Increased trabeculae (A) is incorrect as osteoporosis leads to decreased bone density, not increased. Poor posture (B) may be a result of osteoporosis but is not its primary complication. Chronic pain (C) can occur with osteoporosis but is not as directly linked as fractures.
Which of the following data regarding a client with a diagnosis of colon cancer are subjective?
- A. The client’s chemotherapy causes him nausea and loss of appetite.
- B. The client became teary when his daughter from out of state came to the bedside.
- C. The client’s ileostomy put out 125 mL of effluent in the past four hours.
- D. The patient is unwilling to manipulate or empty his ostomy bag.
Correct Answer: A
Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception.
Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: D
Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
- A. Probenecid (Benemid)
- B. Cytarabine (ara-C, cystosine arabinoside [Cytosar-U])
- C. Thioguanine (6-thioguanine, 6-TG)
- D. Leucovorin (Citrovorum factor or folinic acid [wellcovirin])
Correct Answer: D
Rationale: The correct answer is D, Leucovorin. Leucovorin is administered with methotrexate to protect normal cells from methotrexate toxicity by acting as a "rescue" agent. Methotrexate inhibits dihydrofolate reductase, leading to decreased levels of tetrahydrofolate needed for DNA synthesis. Leucovorin bypasses this step by directly providing the reduced form of folic acid, thus preventing toxicity in normal cells. Probenecid (choice A) is not used to protect normal cells during methotrexate therapy. Cytarabine (choice B) and Thioguanine (choice C) are not rescue agents for methotrexate toxicity.