Nokea
An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
- A. Potential for infection
- B. Self care deficit
- C. Alteration in infection
- D. Fluid volume excess
Correct Answer: A
Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.
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The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
- A. Type A
- B. Type AB
- C. Type B
- D. Type O
Correct Answer: A
Rationale: The correct answer is A: Type A. Individuals with blood type A have a slightly higher risk of developing gastric cancer compared to other blood types. This is due to the presence of certain antigens associated with Type A blood that may increase susceptibility to gastric cancer. In this case, the nurse mentions a 10% increased risk for individuals with Type A blood, which aligns with the known epidemiological data.
Choice B: Type AB is incorrect because individuals with Type AB blood do not have a known increased risk of gastric cancer.
Choice C: Type B is incorrect because individuals with Type B blood do not have a known increased risk of gastric cancer.
Choice D: Type O is incorrect because individuals with Type O blood actually have a slightly lower risk of developing gastric cancer compared to individuals with Type A blood.
A 23 y.o. woman is seen at an outpatient clinic for a routine Pap smear. When questioned, she states she is deciding whether to engage in sexual activity with a man she is just getting to know. She asks how she can tell if he has an STD. Which response by the nurse is best?
- A. “If the man appears clean and has been conscientious about using condoms, he is likely infection free.”
- B. “Look carefully for signs of lesions before engaging in sexual activity.”
- C. “Be sure to use either a male or female condom to protect against possible transmission of infection.”
- D. “An examination by a physician with diagnostic testing is the only way to know if he is infection free.”
Correct Answer: D
Rationale: Step 1: The correct answer is D because it emphasizes the importance of medical examination and diagnostic testing to determine if the man has an STD.
Step 2: Visual inspection (choice B) is not reliable as some STDs may not present with visible symptoms.
Step 3: Relying solely on appearance and condom use (choices A and C) does not guarantee protection against all STDs.
Step 4: Choice D is the best option as it advocates for seeking professional medical advice for accurate diagnosis and treatment.
Mrs. Adams is scheduled for an intravemous pyelogram (IVP). Nurse Aura wpould be most concerned if the patient makes which of the following comments or statements?
- A. ”I take Senokot (laxative) daily.”
- B. “I often feel like my bladder is full even after voiding.”
- C. “My whole face turns red when I eat mussels.”
- D. “I experience headaches every 2 weeks.”
Correct Answer: A
Rationale: The correct answer is A because taking a laxative like Senokot can affect the results of an IVP by altering bowel motility and potentially causing inaccurate imaging. Choice B is related to bladder sensation, which is not directly relevant to an IVP. Choice C indicates a possible allergic reaction to mussels, which is unrelated to the procedure. Choice D mentions headaches, which are also not directly linked to an IVP. In summary, only choice A directly impacts the accuracy of the IVP results, making it the most concerning statement for Nurse Aura.
During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?
- A. An increase in the client’s blood pressure
- B. An increase in the client’s respiratory rate
- C. An increase in the client’s heart rate
- D. A decrease in blood loss
Correct Answer: A
Rationale: The modified Trendelenburg position involves placing the client with their legs elevated higher than their head. This position promotes venous return to the heart, increasing preload and cardiac output, thereby leading to an increase in blood pressure. Elevating the legs helps to reduce peripheral edema and improve circulation. Therefore, the correct answer is A.
Choice B is incorrect because the Trendelenburg position does not directly affect the respiratory rate. Choice C is incorrect as the position is not intended to increase heart rate but rather improve venous return. Choice D is also incorrect as the primary goal of the Trendelenburg position is not to decrease blood loss, although it may help in some cases by improving circulation.
The nurse is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?
- A. Testicular cancer is a highly curable type of cancer.
- B. Testicular cancer is very difficult to diagnose
- C. Testicular cancer is the number one cause of cancer deaths in males.
- D. testicular cancer is more common in older men.
Correct Answer: A
Rationale: The correct answer is A because testicular cancer is indeed a highly curable type of cancer if detected early through self-examinations. This empowers the client to take control of their health. Choice B is incorrect as testicular cancer is detectable through self-examinations. Choice C is incorrect as testicular cancer is not the number one cause of cancer deaths in males; it is relatively rare. Choice D is incorrect as testicular cancer is more common in younger men, typically between the ages of 15 and 44.