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A patient with a new diagnosis of lung cancer decides to have radiation therapy. Which of the ff. expectations of this treatment is most appropriate?
- A. Complete cure of the cancer
- B. Prevention of the need for oxygen
- C. Increased comfort
- D. Prevention of cancer spread
Correct Answer: C
Rationale: The correct answer is C: Increased comfort. Radiation therapy for lung cancer aims to alleviate symptoms, reduce pain, and improve quality of life. It is not typically used as a curative treatment like surgery or chemotherapy (A). It does not prevent the need for oxygen (B), as lung cancer can still affect lung function. While radiation therapy may help control the growth of cancer cells, it is not always effective in preventing cancer spread (D). Therefore, the most appropriate expectation of radiation therapy for lung cancer is increased comfort for the patient.
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With severe diarrhea, electrolytes as well as fluids are lost. What electrolyte imbalance is indicated in Ms. CC’s decreased muscle tone and deep tendon reflexes?
- A. Hypernatremia
- B. Hyperchoremia
- C. Hypokalemia
- D. Hypocalcemia
Correct Answer: D
Rationale: The correct answer is D: Hypocalcemia. Severe diarrhea can lead to electrolyte imbalances, including low calcium levels. Decreased muscle tone and deep tendon reflexes are classic signs of hypocalcemia. Calcium is essential for proper muscle function and nerve transmission. Hypernatremia (A) is high sodium levels, not related to decreased muscle tone. Hyperchloremia (B) is high chloride levels, not associated with muscle tone changes. Hypokalemia (C) is low potassium levels, which can cause muscle weakness but not specifically decreased muscle tone and deep tendon reflexes like hypocalcemia.
A nurse is discharging a client from the hospital. When should discharge planning be initiated?
- A. At the time of discharge from an acute health care setting
- B. At the time of admission to an acute health care setting
- C. Before admission to an acute health care setting
- D. When the client is at home after acute care
Correct Answer: B
Rationale: Rationale:
1. Discharge planning should start at admission to ensure comprehensive preparation.
2. Early planning allows for assessment of needs and coordination of resources.
3. It promotes continuity of care and reduces risks of readmission.
4. Options A, C, and D are incorrect as they miss the opportunity for proactive planning.
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The correct answer is C: Acute pain. The patient's right femur fracture would likely cause significant pain. Treating the pain is a priority to ensure the patient's comfort and promote healing. Posttrauma syndrome (A) is more applicable for patients experiencing emotional distress following a traumatic event. Constipation (B) may be a concern due to immobility but is not as immediate as managing pain. Anxiety (D) may be present but addressing the acute pain would likely alleviate some anxiety as well.
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
- A. Assist the patient to walk in the room with crutches.
- B. Obtain a walker for the patient.
- C. Consult physical therapy.
- D. Administer pain medication.
Correct Answer: D
Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery.
Explanation for other choices:
A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed.
B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain.
C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.
A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [retrovir]), 200mg PO every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
- A. “Take zidovudine with meals.”
- B. “Take zidovudine on an empty stomach.”
- C. “Take zidovudine every 4 hours around the clock.”
- D. “Take over-the-counter(OTC) drugs to treat minor adverse reactions.”
Correct Answer: C
Rationale: The correct answer is C: "Take zidovudine every 4 hours around the clock." Zidovudine is an antiretroviral medication used to treat HIV/AIDS. It is crucial for the client to adhere to the prescribed dosing schedule to maintain therapeutic blood levels. Taking the medication every 4 hours around the clock helps to ensure consistent levels in the body, maximizing its efficacy. Taking it with meals (choice A) or on an empty stomach (choice B) is not specifically indicated for zidovudine. Choice D is incorrect as taking OTC drugs without consulting a healthcare provider can lead to drug interactions or adverse effects. Hence, choice C is the most appropriate instruction to ensure the client benefits from the medication.