Nokea
In monitoring patients who are at risk for spinal cord compression related to tumor growth, what is the most likely early manifestation?
- A. Sudden-onset back pain.
- B. Motor loss.
- C. Constipation.
- D. Urinary hesitancy.
Correct Answer: A
Rationale: Sudden-onset back pain is often the first symptom of spinal cord compression and warrants urgent evaluation.
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To do an effective breast self-examination, when should the woman examine her breasts?
- A. During the fourth to the seventh menstrual cycle day
- B. Every other month
- C. While standing up
- D. 1 week before the menstrual cycle
Correct Answer: A
Rationale: The correct answer is A: During the fourth to the seventh menstrual cycle day. This is because breasts are least likely to be swollen or tender during this time, allowing for a more accurate examination. Choice B is incorrect as regular monthly examinations are recommended. Choice C can be done while standing up or lying down. Choice D is incorrect as breasts may be more tender and swollen closer to the menstrual cycle, making it harder to detect abnormalities.
15. What is the role of the professional nurse related to the use of complementary and alternative therapies (CAT) (select all that apply)?
- A. Seeking further education on CAT
- B. Evaluating the evidence regarding CAT
- C. Collecting data on the use of CAT as part of the nursing assessment
- D. Suggesting specific herbs the patient should take to help with his or her condition
Correct Answer: A
Rationale: Options A, B, and C reflect appropriate roles for nurses in relation to CAT, including seeking education, evaluating evidence, and collecting relevant data during assessments.
When should discharge planning begin for a patient in a tertiary-care facility?
- A. On the day of admission
- B. After the acute crisis is resolved
- C. When the physician writes the discharge order
- D. When the patient demonstrates readiness to discuss posthospitalization needs
Correct Answer: A
Rationale: Rationale:
A: Discharge planning should begin on the day of admission to ensure a smooth transition. This early start allows for comprehensive assessment and coordination of post-discharge needs.
B: Waiting until after the acute crisis is resolved may lead to rushed planning and potential gaps in care.
C: Discharge planning should not solely rely on the physician's discharge order as it may not address all aspects of the patient's needs.
D: Patient readiness is important, but starting planning early ensures sufficient time for assessment and interventions.
A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?
- A. Chest tube eyelets not visible
- B. Continuous bubbling in the suction control chamber
- C. Presence of tidal fluctuation in the water seal chamber
- D. Development of subcutaneous emphysema
Correct Answer: D
Rationale: The correct answer is D: Development of subcutaneous emphysema. This finding indicates air leakage, which can lead to potential complications like tension pneumothorax. Subcutaneous emphysema is a serious concern that requires immediate intervention.
A: Chest tube eyelets not visible - This is not a concerning finding as long as the chest tube is properly secured and functioning.
B: Continuous bubbling in the suction control chamber - This can indicate proper functioning of the system.
C: Presence of tidal fluctuation in the water seal chamber - This indicates that the system is working correctly, with the water seal chamber fluctuating with the patient's breathing.
After implementing nursing interventions for a client with anxiety, which expected outcome does the nurse evaluate?
- A. The client avoids all kinds of anxiety-provoking stimuli
- B. The client has no need for written instructions for follow-up care
- C. The client accurately repeats information about the drug therapy
- D. There are no consequences if anxiolytic drug is discontinued suddenly
Correct Answer: C
Rationale: Accurate understanding of drug therapy ensures compliance and safety, reducing the risk of adverse effects.