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 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 because the problem-oriented approach involves focusing on the patient's presenting situation to identify the main issues and prioritize data collection. This step helps the nurse understand the immediate concerns and sets the direction for further assessment and interventions.
Choice A is incorrect because completing questions in chronological order may not address the most urgent issues. Choice C is incorrect as accurate interpretations come after collecting relevant data. Choice D is incorrect as conducting an observational overview is part of the assessment process but not the first step in the problem-oriented approach.
What is the rationale for giving Mr. Franco frequent mouth care?
- A. He will be thirsty considering that he is doesn’t drink enough fluids
- B. To remove dried blood when tongue is bitten during a seizure
- C. The tactile stimulation during mouth care will hasten return to consciousness
- D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.
Correct Answer: B
Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco helps in removing dried blood when his tongue is bitten during a seizure, preventing infection and promoting oral hygiene. This is crucial in preventing complications and ensuring Mr. Franco's overall well-being.
Choice A is incorrect because thirst is not directly related to mouth care, and increasing fluids intake would address dehydration more effectively. Choice C is incorrect as tactile stimulation may not necessarily hasten return to consciousness in this context. Choice D is incorrect as it refers to a different issue related to mouth breathing in comatose patients, which is not the immediate concern addressed by frequent mouth care in this scenario.
Which part of the body is supplied by nerves form the thoracic cord?
- A. Head
- B. Pelvis
- C. Trunk
- D. Coccyx
Correct Answer: C
Rationale: The correct answer is C: Trunk. The thoracic cord supplies nerves to the trunk region of the body. The thoracic spinal nerves innervate the chest, abdomen, and back. They control sensation and movement in these areas. The head (A) is mainly supplied by cranial nerves, the pelvis (B) is innervated by lumbar and sacral nerves, and the coccyx (D) is supplied by the sacral nerves. Therefore, the correct answer is C as it aligns with the anatomical distribution of the thoracic spinal nerves.
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.
During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?
- A. “The head of your bed must remain flat for 24 hours after surgery.”
- B. “You should avoid deep breathing and coughing after surgery.”
- C. “You won’t be able to swallow for the first day or two.”
- D. “You must avoid hyperextending your neck after surgery.”
Correct Answer: D
Rationale: The correct answer is D: “You must avoid hyperextending your neck after surgery.” This is because hyperextending the neck can put excessive strain on the surgical site, leading to potential complications such as bleeding or injury to the incision. Keeping the neck in a neutral position helps promote healing and reduces the risk of complications.
A: “The head of your bed must remain flat for 24 hours after surgery.” - Incorrect. Elevating the head of the bed can help reduce swelling and promote drainage after thyroidectomy.
B: “You should avoid deep breathing and coughing after surgery.” - Incorrect. Deep breathing and coughing are important to prevent respiratory complications such as pneumonia.
C: “You won’t be able to swallow for the first day or two.” - Incorrect. Swallowing may be difficult initially but should improve gradually after surgery.