Nokea
Patient S is a sexually active adolescent; which of the following instructions would be included in the preventive teaching plan about urinary tract infections?
- A. Drinking acidic juices
- B. Avoiding urinating before intercourse
- C. Wearing nylon underwear
- D. Wiping back to front
Correct Answer: A
Rationale: Drinking acidic juices, such as cranberry juice, can help make the urine more acidic, which can potentially prevent bacteria from sticking to the urinary tract walls and reduce the risk of urinary tract infections. It is important to note that while acidic juices can be beneficial in some cases, they should not be relied upon as the sole preventive measure for UTIs. Other important preventive measures include staying hydrated, practicing good hygiene, and urinating before and after intercourse.
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During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
- A. Recommending that the client discontinue chemotherapy
- B. Providing a solution of hydrogen peroxide and water for use as a mouth rinse
- C. monitoring the client's platelet and leukocyte counts
- D. Checking regularly for signs and symptoms of stomatitis
Correct Answer: B
Rationale: Providing a solution of hydrogen peroxide and water for use as a mouth rinse is most likely to decrease the pain of stomatitis. Stomatitis is inflammation of the oral mucous membranes and can be quite painful for oncology clients undergoing chemotherapy. Using a solution of hydrogen peroxide and water as a mouth rinse can help reduce the risk of infection and promote healing of the mucous membranes, thereby decreasing the pain associated with stomatitis. This intervention helps to maintain oral hygiene and prevent further complications, making it an effective way to manage the client's symptoms while undergoing chemotherapy. It is important to note that discontinuing chemotherapy would not be a recommended intervention as it is the primary treatment for the client's cancer. Monitoring platelet and leukocyte counts and checking for signs and symptoms of stomatitis are important aspects of care, but providing a mouth rinse would directly address the pain and discomfort experienced by the client.
Why must clients who will undergo diagnostic skin test avoid taking antihistamine or cold preparations for at least 48-72 hrs before testing?
- A. Antihistamines may increase the potential for excessive bleeding
- B. Antihistamines may aggravate the allergic reaction
- C. Antihistamines may increase the potential for false negative results
- D. Antihistamines may cause wheezing
Correct Answer: C
Rationale: Antihistamines are medications commonly used to relieve symptoms of allergies, including itching, sneezing, and hives. When a client undergoing a diagnostic skin test for allergies takes antihistamines, it can suppress the body's allergic response, leading to false negative results. This means that the test may not accurately identify all the substances to which the client is allergic, potentially leading to a misdiagnosis. To ensure the accuracy of the skin test, clients are advised to avoid taking antihistamines or cold preparations for at least 48-72 hours before the testing to allow their body to exhibit the appropriate allergic response.
A 3-year-old female is hospitalized for a femur fracture. As her nurse, what nursing action would help foster the child's sense of autonomy?
- A. Allow the child to choose what time to take her oral antibiotics.
- B. Allow the child to have a doll for medical play.
- C. Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe.
- D. Allow the child to watch age-appropriate videos.
Correct Answer: B
Rationale: Allowing preschoolers to participate in actions for which they are capable is an excellent way to enhance their sense of autonomy.
The primary critical observation for Apgar scoring is the:
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of the Moro reflex
Correct Answer: A
Rationale: The primary critical observation for Apgar scoring is the heart rate. This is because the heart rate is vital for life and immediate assessment of the infant's heart rate provides crucial information about the baby's overall well-being and response to the birthing process. The Apgar score assesses five components: heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. Among these components, the heart rate is considered the most critical because it directly reflects the infant's cardiovascular status and their ability to maintain adequate perfusion of vital organs. Therefore, for quick assessment and immediate intervention, the heart rate is prioritized as the primary observation in Apgar scoring.
A 10-mo-old boy has a left suprarenal mass. Surgery is accomplished with complete removal of the mass as well as the non-adherent lymph nodes; surgical biopsies are taken during surgery. The histology reveals poorly differentiated neuroblastoma with microscopic ipsilateral lymph nodes involvement. The contralateral lymph nodes are negative. Of the following, the BEST therapeutic approach for this infant is
- A. chemotherapy
- B. radiotherapy
- C. concomitant chemo-radiotherapy
- D. chemotherapy followed by radiotherapy
Correct Answer: A
Rationale: Complete resection with microscopic residual disease typically warrants adjuvant chemotherapy.