Nokea
During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi’s sarcoma
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. In AIDS patients, Kaposi’s sarcoma is a common cancer caused by human herpesvirus 8. It presents as purple or brown skin lesions. Squamous cell carcinoma (A), leukemia (B), and multiple myeloma (C) are not commonly associated with AIDS. Squamous cell carcinoma is linked to sun exposure, leukemia originates in the bone marrow, and multiple myeloma is a cancer of plasma cells. Therefore, the correct answer is D due to its strong association with AIDS.
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A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self- examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. Mobile mass that is soft and easily
- C. Non-mobile mass with irregular edges delineated
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C: Non-mobile mass with irregular edges delineated. This finding strongly suggests cancer as non-mobile masses with irregular edges are characteristic of malignant tumors. Cancerous lumps tend to be fixed in place due to involvement of surrounding tissues. Irregular edges indicate potential invasive growth. Choices A and B describe characteristics more commonly associated with benign masses. Eversion of the nipple is concerning for cancer but not specific enough to strongly suggest malignancy. Choice D indicates absence of lymph node involvement, which is not directly related to the characteristics of the breast lump.
A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:
- A. abdominal pain related to decreased peristalsis
- B. diarrhea related to hyperosmolar intestinal contents
- C. fluid volume excess related to increase water absorption by intestinal mucosa
- D. activity intolerance related to fatigue
Correct Answer: A
Rationale: The correct answer is A: abdominal pain related to decreased peristalsis. Ulcerative colitis causes inflammation and ulcers in the colon, leading to abdominal pain due to decreased peristalsis. This impairs the movement of stool through the colon, resulting in pain.
Choice B is incorrect as diarrhea is a common symptom of ulcerative colitis, not hyperosmolar intestinal contents. Choice C is incorrect as ulcerative colitis often leads to diarrhea and not fluid volume excess. Choice D is incorrect as activity intolerance is not directly related to ulcerative colitis, whereas abdominal pain is a common symptom associated with the condition.
24 hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:
- A. Removal of the transplanted kidney
- B. High-dose IV cyclosporine (Sandimmune) therapy
- C. Bone marrow transplant
- D. Intra-abdominal instillation of methylprednisolone sodium succinate (Solu-Medrol)
Correct Answer: A
Rationale: The correct answer is A: Removal of the transplanted kidney. Hyperacute rejection is a severe and immediate immune response to the transplanted organ. In this case, the transplanted kidney must be removed promptly to prevent further complications, as it is irreversibly damaged. High-dose IV cyclosporine (B) is used for immunosuppression but is not effective in treating hyperacute rejection. Bone marrow transplant (C) is not indicated for kidney rejection. Intra-abdominal instillation of methylprednisolone sodium succinate (D) is used for acute rejection, not hyperacute rejection.
A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he 'can’t live with this fear.' Which of the following diagnoses for this client is correctly written?
- A. Post-trauma syndrome related to being attacked
- B. Psychological overreaction related to being attacked
- C. Needs assistance coping with attack
- D. Mental distress related to being attacked
Correct Answer: A
Rationale: The correct answer is A: Post-trauma syndrome related to being attacked. This diagnosis accurately reflects the client's symptoms of reliving the traumatic event, crying uncontrollably, and expressing fear. "Post-trauma syndrome" encompasses the psychological and emotional distress following a traumatic event.
Choice B: Psychological overreaction simplifies the client's experience and does not capture the severity or ongoing nature of the trauma symptoms.
Choice C: Needs assistance coping with attack is vague and does not provide a specific diagnosis or acknowledge the clinical presentation of the client.
Choice D: Mental distress related to being attacked is too broad and does not specify the specific syndrome or symptoms experienced by the client.
A client, age 42, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?
- A. Onset of sporadic sexual activity at age 17
- B. Pregnancy complicated with eclampsia at
- C. Spontaneous abortion at age 19 age 27
- D. Human papilloma virus infection at age 32
Correct Answer: D
Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV is a known risk factor for cervical cancer as it can lead to cellular changes in the cervix. Here's the rationale:
1. HPV is a sexually transmitted infection that can cause abnormal cell growth in the cervix.
2. Persistent HPV infection is a major risk factor for developing cervical cancer.
3. Age 32 is within the typical age range for HPV infection and the development of cervical cancer.
4. Choices A, B, and C are unrelated to the primary risk factor for cervical cancer, which is HPV infection.