Nokea
A patient is diagnosed with acute bacterial conjunctivitis. In providing patient teaching the nurse would tell the patient that this condition is more commonly known as which of the following?
- A. Glaucoma
- B. Color blindness
- C. Astigmatism
- D. Pinkeye
Correct Answer: D
Rationale: The correct answer is D: Pinkeye. Acute bacterial conjunctivitis is commonly referred to as "pinkeye" due to the characteristic pink or red appearance of the eye. This condition is caused by a bacterial infection of the conjunctiva, the thin membrane that covers the white part of the eye and inner eyelids. The term "glaucoma" (A) refers to a different eye condition characterized by increased intraocular pressure, while "color blindness" (B) is a genetic condition affecting color vision. "Astigmatism" (C) is a refractive error related to the shape of the cornea or lens, not an infection of the eye. Therefore, the correct answer is D as it accurately identifies the common name for acute bacterial conjunctivitis.
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A client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect:
- A. Hair loss.
- B. Fatigue.
- C. Stomatitis.
- D. Vomiting.
Correct Answer: A
Rationale: The correct answer is A: Hair loss. Radiation therapy targets fast-growing cancer cells, which can also affect healthy cells such as those in hair follicles, leading to hair loss. This adverse effect occurs commonly with radiation therapy due to its impact on rapidly dividing cells. Hair loss is a well-known side effect that clients undergoing radiation therapy are often prepared for. The other choices, B: Fatigue, C: Stomatitis, and D: Vomiting, are also potential side effects of radiation therapy, but hair loss is specifically associated with radiation treatment due to its effect on hair follicles. Fatigue is a common side effect of cancer treatment in general, stomatitis is more commonly associated with chemotherapy, and vomiting can be a side effect of radiation but is not as directly linked as hair loss.
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. Soap can irritate the skin and exacerbate the risk for impaired skin integrity in a client receiving radiation therapy. By avoiding soap, we minimize the risk of skin breakdown and promote skin healing.
B: Applying talcum powder can actually worsen skin irritation and should be avoided.
C: Wearing a lead apron is not relevant to the nursing diagnosis of risk for impaired skin integrity.
D: Removing thoracic skin markings is not necessary for skin integrity and may disrupt the treatment plan.
Which of the ff. conditions places a patient at risk for respiratory complications following his splenectomy?
- A. A low platelet count
- B. Early ambulation
- C. An incision near the diaphragm
- D. Early discharge
Correct Answer: C
Rationale: The correct answer is C: An incision near the diaphragm. Following a splenectomy, an incision near the diaphragm can lead to respiratory complications due to potential irritation or injury to the diaphragm. This can result in impaired breathing and increased risk of respiratory issues such as pneumonia.
A: A low platelet count is not directly related to respiratory complications following a splenectomy.
B: Early ambulation is generally encouraged to prevent complications such as blood clots but does not specifically impact respiratory complications.
D: Early discharge may not directly lead to respiratory complications, as long as the patient is adequately monitored postoperatively.
The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone
- B. Observe for swelling of the neck, tracheal deviation, and severe pain
- C. Evaluate the quality of the client’s voice postoperatively, noting any dastric changes
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes
Correct Answer: D
Rationale: The correct answer is D: Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. After a thyroidectomy, the parathyroid glands may be inadvertently damaged, leading to hypocalcemia. Muscle twitching and numbness/tingling are early signs of hypocalcemia. The nurse should monitor for these symptoms to detect and address hypocalcemia promptly.
Choice A is incorrect as monitoring thyroid-stimulating hormone levels is not related to hypocalcemia. Choice B is incorrect as it describes signs of potential complications like bleeding or airway obstruction, not hypocalcemia. Choice C is incorrect as changes in voice quality and gastric issues are not specific to hypocalcemia.
A 17-year-old student enters the emergency department with a nosebleed that won’t quit. Which of the following positions is recommended for the patient with a nosebleed?
- A. Lying down with feet elevated
- B. Sitting up with neck extended
- C. Lying down with a small pillow under the head
- D. Sitting up leaning slightly forward
Correct Answer: D
Rationale: The correct answer is D: Sitting up leaning slightly forward. This position helps prevent blood from flowing back into the throat, reducing the risk of choking and aspiration. It also allows for better drainage of blood out of the nose. Lying down with feet elevated (choice A) can increase blood flow to the head and worsen the nosebleed. Sitting up with neck extended (choice B) can lead to blood flowing into the throat. Lying down with a small pillow under the head (choice C) may cause blood to flow backward.