Nokea
The nurse assesses that the client who is receiving radiation for cervical cancer continues to have diarrhea. Which nursing advice is most appropriate for this client?
- A. Eat a low-residue diet and take sitz baths twice daily.
- B. Drink fluids low in potassium and take frequent tub baths.
- C. Consume more milk products and take frequent showers.
- D. Drink high-sodium fluids and apply hydrocolloid pads to rectum.
Correct Answer: A
Rationale: A. The client with diarrhea should eat a low-residue diet to decrease roughage and bowel irritability and take sitz (or tub) baths twice daily to increase comfort. B. Intake of fluids that are high in potassium (not low) is recommended to replace electrolytes lost through diarrhea. C. Milk products are discouraged because they increase bowel irritability. D. Intake of fluids high in sodium should be avoided because it contributes to water retention, but hydrocolloid pads may be used on reddened areas to promote healing.
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The client is being admitted with folic acid deficiency anemia. Which would be the most appropriate referral?
- A. Alcoholics Anonymous.
- B. Leukemia Society of America.
- C. A hematologist.
- D. A social worker.
Correct Answer: C
Rationale: Folic acid deficiency anemia requires a hematologist (C) for evaluation/treatment. AA (A) is for alcoholism, Leukemia Society (B) is unrelated, and social work (D) is secondary.
Which sign/symptom should the nurse expect to assess in the client diagnosed with hemophilia A?
- A. Epistaxis.
- B. Petechiae.
- C. Subcutaneous emphysema.
- D. Intermittent claudication.
Correct Answer: A
Rationale: Hemophilia A causes bleeding; epistaxis (A) is common. Petechiae (B) indicate thrombocytopenia, emphysema (C) is unrelated, and claudication (D) is vascular.
The client with COPD has developed polycythemia vera, and the nurse completes teaching on measures to prevent complications. During a home visit, the nurse evaluates that the client is correctly following the teaching when which actions are noted?
- A. Tells the nurse about discontinuing iron supplements.
- B. States increasing alcohol intake to decrease blood viscosity.
- C. Presents a record that shows a daily fluid intake of 3000 mL.
- D. Discusses yesterday’s phlebotomy treatment to remove blood.
- E. Shows the nurse 3 menu plan for eating three large meals daily.
- F. Wears antiembolic stockings and sits in a recliner with legs uncrossed
Correct Answer: A, C, D, F
Rationale: Iron supplements, including those in multi-vitamins, should be avoided because the iron stimulates RBC production. B. Alcohol increases the risk of bleeding. C. Increasing fluid intake to 3000 mL daily will help decrease blood viscosity. D. Phlebotomy is performed on a routine or intermittent basis to diminish blood viscosity, deplete iron stores, and decrease the client’s ability to manufacture excess erythrocytes. E. Frequent, small meals are better tolerated, especially if the liver is involved. F. Elevating the legs, avoiding constriction or crossing the legs, and wearing antiembolic stockings help prevent DVT.
The nurse is assessing a client diagnosed with vaso-occlusive crisis. Which indicates the client is not meeting an appropriate stage of growth and development according to Erikson?
- A. The 32-year-old client does not have a significant other and is on disability.
- B. The 28-year-old client is actively involved in the care of a six (6)-year-old child.
- C. The 40-year-old client has a full-time job and cares for an aged parent.
- D. The 19-year-old client is a full-time college student and has many friends.
Correct Answer: A
Rationale: At 32 (Intimacy vs. Isolation), lack of a significant other and disability (A) suggest isolation, not meeting Erikson’s stage. Parenting (B), caregiving (C), and socializing (D) align with Generativity, Generativity, and Identity stages.
The young adult, diagnosed with hemophilia A, is receiving a monthly scheduled dose of factor VIII cryoprecipitate. The client begins to cry during administration. Which response by the nurse is most appropriate?
- A. “Why are you crying? You seem afraid when I am administering the drug.”
- B. “Is it painful while I’m giving this IV push? If so, I can give it by infusion.”
- C. “I know this is uncomfortable for you; this only takes a few minutes to give.”
- D. “If you want to talk to me about what you are feeling, I am here to listen.”
Correct Answer: D
Rationale: A. Asking a “why” question challenges the client’s feelings. B. This response seeks information but is not most appropriate. It is unlikely that the initial response from an adult would not be crying if the administration of IV factor VIII cryoprecipitate by IV push were painful. C. This response ignores the client’s feelings and presumes that the nurse knows what initiated the client’s crying. D. The nurse is offering self, which is a therapeutic communication technique.