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: Monitoring food intake is a straightforward task suitable for a nursing assistant, while identifying fatigue patterns or recommending exercise requires more clinical expertise.
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What are the priority nursing diagnoses for a client in shock?
- A. Increased urine output
- B. Edema
- C. Hypertension
- D. Hypernatremia
Correct Answer: B
Rationale: Edema occurs due to excess fluid accumulation in the interstitial spaces, commonly seen in conditions like heart failure and kidney disease.
On assessing Mr. Puff, what would you expect to find?
- A. ‘Blue bloater’ appearance
- B. Copious amount of thin sputum
- C. Increased anteroposterior chest diameter
- D. Prolonged inspiratory time
Correct Answer: C
Rationale: The correct answer is C: Increased anteroposterior chest diameter. In patients with chronic obstructive pulmonary disease (COPD), like Mr. Puff, there is often air trapping leading to hyperinflation of the lungs. This results in an increased anteroposterior chest diameter, known as a "barrel chest" appearance. Option A (‘Blue bloater’ appearance) is associated with chronic bronchitis, not necessarily COPD. Option B (Copious amount of thin sputum) is more indicative of bronchiectasis. Option D (Prolonged inspiratory time) is a nonspecific finding and not typically associated with COPD.
Limited health literacy may be associated with which conditions that lead to health disparities?
- A. Age
- B. Place
- C. Gender
- D. Race/ethnicity
Correct Answer: A
Rationale: Health literacy issues often correlate with age, place, race/ethnicity, language barriers, and income/education. Gender is less directly tied but still relevant in some contexts.
Following chemotherapy, a patient is being closely monitored for tumor lysis syndrome. Which laboratory value requires particular attention?
- A. Platelet count.
- B. Electrolytes.
- C. Hemoglobin.
- D. Hematocrit.
Correct Answer: B
Rationale: Electrolyte imbalances, particularly hyperkalemia and hyperuricemia, are hallmark features of tumor lysis syndrome and must be closely monitored.
Seven tasks required for daily living with chronic illness have been identified. From Table 5-4, select at least one of these tasks that would specifically apply to the following common chronic conditions in older adults.
- A. Diabetes mellitus
- B. Visual impairment
- C. Heart disease
- D. Hearing impairment
Correct Answer: A
Rationale: Each chronic condition requires specific daily living tasks: Diabetes involves monitoring blood sugar; visual impairment may require adaptive techniques; heart disease necessitates lifestyle modifications; hearing impairment might involve using assistive devices.