Nokea
The nurse assesses a client with a below-knee amputation for prosthetic fitting. Which finding indicates readiness for a prosthesis?
- A. Full range of motion in the residual limb.
- B. Absence of pain in the stump.
- C. Healed incision with no drainage.
- D. Presence of mild edema in the stump.
Correct Answer: C
Rationale: A healed incision without drainage is essential for safe prosthetic fitting to prevent skin breakdown.
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A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal to address for the client is:
- A. Fear of pain.
- B. Fear of further therapy.
- C. Feelings of isolation.
- D. Feelings of social inadequacy.
Correct Answer: A
Rationale: In hospice care for advanced Hodgkin's disease, the primary goal is to address fear of pain, ensuring comfort as death approaches. Fear of therapy, isolation, and social inadequacy are less relevant at this stage.
To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following?
- A. Sit upright for 30 minutes after meals.
- B. Drink liquids with meals, avoiding caffeine.
- C. Avoid milk and other dairy products.
- D. Decrease the carbohydrate content of meals.
Correct Answer: D
Rationale: Decreasing carbohydrate content helps slow gastric emptying, reducing the risk of dumping syndrome. Sitting upright is helpful but less specific, and drinking liquids with meals can worsen symptoms.
Which teaching point is essential for a client with a seizure disorder?
- A. Avoid all physical activity.
- B. Take medications as prescribed.
- C. Limit sleep to 6 hours nightly.
- D. Restrict fluid intake.
Correct Answer: B
Rationale: Taking medications as prescribed is essential to control seizures and prevent recurrence.
The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses/treats bleeding, blood products (C) address hypovolemia, and Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention, not immediate.
A 42-year-old female highway construction worker is concerned about her cancer risks. She reveals that she has been married for 18 years, has two children, smokes one pack of cigarettes per day, and drinks one to two beers with her husband after work almost every day. She is 30 lb overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What combination of behavioral changes should the nurse instruct this client to make first?
- A. Decrease fat in the diet, decrease alcohol consumption, and use sunscreen every day.
- B. Decrease intake of salt-cured food, lose weight, and stop smoking.
- C. Stop drinking beer, decrease fiber in the diet, and use sun protection.
- D. Stop smoking, use sun protection, and lose weight.
Correct Answer: D
Rationale: Stopping smoking, using sun protection, and losing weight address the most critical modifiable risk factors for this client, given her smoking history, prior skin cancer, and obesity, which are linked to multiple cancers.