Nokea
For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to the nursing assistant?
- A. Assist the patient to identify patterns of fatigue
- B. Recommend participation in a walking program
- C. Report the amount and type of food consumed from the tray
- D. Check the skin for redness and irritation after the treatment
Correct Answer: C
Rationale: Radiation side effects like fatigue and anorexia benefit from team care. Reporting food consumed from the tray suits nursing assistants observing and relaying intake data supports nutrition monitoring without requiring clinical judgment. Identifying fatigue patterns demands analysis, a nurse's role to adjust care plans. Recommending exercise exceeds assistants' scope physicians or RNs initiate such advice. Checking skin for redness post-treatment needs assessment skills to detect burns or infection, RN territory. Food reporting leverages assistants' observational role, aiding nurses in tracking radiation's impact on appetite, ensuring basic needs are flagged efficiently in a collaborative approach.
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The definition of Chronic Heart Failure is:
- A. Failure of the heart to adequately pump blood to the body.
- B. Long-term inability of the heart to meet metabolic demands required to maintain homeostasis.
- C. Prolonged enlargement of the left ventricle impacting on the contractility of the muscle.
- D. Long term fluid build-up, causing increase in blood volume and reducing the ability of the heart to maintain blood flow.
Correct Answer: B
Rationale: Chronic heart failure (CHF) is a syndrome, not a singular defect. Failure to pump adequately describes acute failure but lacks chronicity's scope. CHF is the heart's prolonged inability to meet metabolic demands for oxygen and nutrients, disrupting homeostasis per Farrell (2017) encompassing systolic (reduced ejection) and diastolic (impaired filling) dysfunction. Left ventricular enlargement may occur (e.g., dilated cardiomyopathy), but it's a cause or result, not the definition; contractility varies. Fluid buildup (congestion) is a feature, not the essence blood volume rises secondary to neurohormonal activation (e.g., renin-angiotensin system), not as the primary failure. The metabolic demand focus captures CHF's systemic impact fatigue, edema, dyspnea reflecting chronic adaptation failure over structural or fluid-centric descriptions.
A nurse is performing discharge teaching for a client who was recently diagnosed with heart failure. Which of the following should be included in the client and family teaching?
- A. Low sodium diet
- B. Weekly weights
- C. Symptoms to report to the provider
- D. Fluid restriction
Correct Answer: A
Rationale: Heart failure management hinges on education to prevent exacerbations. A low sodium diet reduces fluid retention, easing cardiac workload crucial teaching for clients and families to grasp, as salt drives edema and hypertension, common pitfalls in heart failure. Weekly weights track fluid shifts daily is ideal, but weekly still aids while reporting symptoms like dyspnea flags worsening. Medication teaching ensures adherence, and fluid restriction may apply, but sodium's broader impact makes it foundational. Focusing on diet empowers lifestyle change, tackling a root cause over monitoring or restrictions alone, aligning with nursing's role in empowering self-care to stabilize this chronic condition long-term.
The nurse caring for oncology clients knows that which form of metastasis is the most common?
- A. Bloodborne
- B. Direct invasion
- C. Lymphatic spread
- D. Via bone marrow
Correct Answer: A
Rationale: Metastasis is the process by which cancer spreads from its original site to distant parts of the body, a critical concern in oncology nursing. Among the various mechanisms, bloodborne metastasis is the most common, as cancer cells often enter the bloodstream and travel to organs like the lungs, liver, or brain. This occurs because the circulatory system provides an efficient pathway for tumor cells to disseminate widely, especially in cancers like breast or lung cancer. Lymphatic spread is also frequent, particularly in carcinomas, where cells travel via lymph nodes, but it is less dominant than bloodborne spread across all cancer types. Direct invasion involves cancer growing into adjacent tissues, which is a local process rather than true metastasis. Bone marrow is not a medium for metastasis but a potential site where cancer can settle, such as in leukemia or multiple myeloma. Understanding that bloodborne metastasis predominates helps nurses prioritize monitoring for systemic symptoms and complications, such as organ dysfunction, in clients with advanced cancer.
It is the start of your second successive night shift on the labour ward. You have only managed to sleep for 4 h in the previous day. Your usual sleep requirement is 8 h per night. Appropriate statements regarding this situation include:
- A. Your total cumulative sleep deficit is 8 h.
- B. Your alertness will increase between 3 a.m. and 7 a.m. due to natural fluctuation in your circadian rhythm.
- C. Unintentional dural puncture during epidural insertion is more likely to occur during a night shift than during normal working hours.
- D. Sleeping for an extra 4 h will eliminate the sleep deficit.
Correct Answer: C
Rationale: Night shifts disrupt sleep and performance. After one night with 4 hours sleep (8-hour need), the deficit is 4 hours; a second night compounds it variably, but total' implies current state 8 hours overstates it without further context. Alertness dips 3-7 a.m. (circadian nadir), not increases, heightening fatigue. Night-shift studies (e.g., anaesthesia journals) show increased errors like dural puncture due to fatigue, reduced dexterity, and decision-making capacity, especially with sleep deprivation. Four extra hours reduce, not eliminate, a deficit if it's 4-12 hours cumulatively. Modafinil promotes wakefulness, not daytime sleep. The night-shift risk of dural puncture reflects fatigue's real-world impact on technical skills.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?
- A. The patient ambulates several times a day in the room
- B. The patient's visitors bring in some fresh peaches from home
- C. The patient cleans with a warm washcloth after having a stool
- D. The patient uses soap and shampoo to shower every other day
Correct Answer: B
Rationale: Neutropenia post-chemo low neutrophils craves germ-free zones; fresh peaches from home carry bacteria, a teaching gap as raw produce risks infection in this immune-wrecked state. Ambulation's safe, hygiene's spot-on washcloths and showers cut germs. Nurses reteach, banning unwashed fruit, a vital shield in leukemia's neutropenic peril, ensuring clients grasp this microbial minefield.