Nokea
Biopsy is a diagnostic procedure which:
- A. Detects the presence of malignant cells
- B. Measures hemoglobin content
- C. Measures the RBC size
- D. Detects arterial occlusion Situation: Cancer ranks third in leading cause of morbidity and mortality in the Philippines. Early detection Increases the survival rate of those afflicted. You are a nurse in a cancer-prevention and screening clinic and are for health education.
Correct Answer: A
Rationale: The correct answer is A: Detects the presence of malignant cells. Biopsy involves taking a sample of tissue to examine under a microscope for the presence of abnormal or cancerous cells. This procedure is crucial for diagnosing cancer accurately.
Choice B (Measures hemoglobin content) is incorrect because hemoglobin content is typically measured through blood tests, not biopsies.
Choice C (Measures the RBC size) is incorrect as RBC size is usually assessed through a complete blood count (CBC) test, not a biopsy.
Choice D (Detects arterial occlusion) is incorrect because arterial occlusion is typically diagnosed through imaging studies like Doppler ultrasound or angiography, not through a biopsy procedure.
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A client in the final stages of terminal cancer tells the nurse: “I wish I could be just be allowed to die. I’m tired of fighting this illness. I have lived life a good life. I only continue my chemotherapy and radiation treatment because my family wants me to.” What is the best nurse’s best response?
- A. “Would you like to talk to a psychologist about your thoughts and feelings?”
- B. “Would you like to talk to your minister about the significance of death?”
- C. “Would you like to meet with your family and your physician about this matter?”
- D. “I know you are tired of fighting this illness, but death will come in due time.”
Correct Answer: C
Rationale: The correct response is C: “Would you like to meet with your family and your physician about this matter?”
Rationale:
1. Involving the family and physician ensures a collaborative decision-making process.
2. It respects the client's autonomy and involves them in the decision-making process.
3. It promotes open communication and support from loved ones.
4. It addresses the client's concerns about continuing treatment based on family wishes.
Summary:
A: Refers to psychological support, but the client's primary concern is medical treatment decisions.
B: Involves religious support, which may not align with the client's beliefs or address the medical decision.
D: Acknowledges the client's feelings but lacks a collaborative approach involving family and healthcare team.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care.
Incorrect choices:
A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details.
C: Making accurate interpretations of the data comes after data collection, so it is not the first step.
D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.
During a breast examination, which finding most strongly suggests that the client has breast cancer?
- A. Slight asymmetry of the breasts
- B. A fixed nodular mass with dimpling of the overlying skin
- C. Bloody discharge from the nipple
- D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B
Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is highly indicative of breast cancer. This finding suggests an invasive tumor pulling on the skin, causing dimpling. Other choices are incorrect because slight breast asymmetry (A) is common, bloody nipple discharge (C) can be benign or due to other conditions, and multiple freely movable masses (D) are more indicative of benign breast conditions like fibrocystic changes.
Mr. Sison had an above the knee amputation (AKA). He is taught to use crutches while prosthesis is being adjusted. The nurse instruct the client to support her weight primarily on which areas?
- A. axilla
- B. upper arms
- C. elbows
- D. hands
Correct Answer: A
Rationale: The correct answer is A: axilla. When using crutches, weight should primarily be supported on the axilla to prevent nerve and blood vessel damage in the armpit area. Supporting weight on the upper arms (B) can lead to nerve compression and muscle strain. Supporting weight on the elbows (C) can cause nerve damage and discomfort. Supporting weight on the hands (D) can lead to hand and wrist pain and may not provide stable support. Therefore, the axilla is the most appropriate area to support weight while using crutches to ensure safety and comfort for the client.
The knows that a positive diagnosis for HIV infection is made based on; a.A history of high-risk sexual behaviors
- A. Positive ELISA and Western blot tests
- B. Evidence of extreme weight loss and high fever
- C. Identification of an associated opportunistic infection
Correct Answer: A
Rationale: The correct answer is A because a positive diagnosis for HIV infection is confirmed through laboratory testing, specifically the ELISA and Western blot tests. These tests detect the presence of HIV antibodies in the blood, providing definitive evidence of the infection. Choice B is incorrect as weight loss and fever are symptoms but not diagnostic criteria. Choice C is incorrect as opportunistic infections are a consequence of HIV, not the diagnostic criteria. Choice D is incomplete and irrelevant. In summary, the key to diagnosing HIV is through positive laboratory tests, not just based on symptoms or associated infections.