Nokea
The nurse caring for a client who is receiving radiation therapy for laryngeal cancer should assess the client for which of the following?
- A. Diarrhea.
- B. Improved energy level.
- C. Dysphagia.
- D. Normal white blood cell count.
Correct Answer: C
Rationale: Dysphagia (difficulty swallowing) is a common side effect of laryngeal radiation due to inflammation and irritation of the throat and esophagus.
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A client has a positive reaction to the Mantoux test. The nurse correctly interprets this reaction to mean that the client has:
- A. Active tuberculosis.
- B. Had contact with Mycobacterium tuberculosis.
- C. Developed a resistance to tubercle bacilli.
- D. Developed passive immunity to tuberculosis.
Correct Answer: B
Rationale: A positive Mantoux test indicates exposure to Mycobacterium tuberculosis, not necessarily active disease. It does not imply resistance or passive immunity.
The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
- A. Ensuring adequate fluid intake on the day of the test.
- B. Preparing the client for the possibility of bladder, the client is history for allergy to iodine.
- C. Determining when the client last had a bowel movement.
Correct Answer: B
Rationale: Checking for iodine allergy is critical for IVP due to the use of iodine-based contrast, which can cause severe allergic reactions.
The nurse receives the following critical laboratory results for a client with end-stage renal disease. The nurse anticipates the physician to prescribe which blood product? See the image below.
- A. Packed Red Blood Cells (PRBCs)
- B. Fresh Frozen Plasma (FFP)
- C. Albumin
- D. Platelets
Correct Answer: A
Rationale: End-stage renal disease often leads to anemia due to decreased erythropoietin production, making PRBCs the likely prescribed blood product to correct severe anemia. FFP, albumin, and platelets address other issues not typically primary in this context.
When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by:
- A. Left ventricular overload.
- B. Impending circulatory collapse.
- C. Extracellular electrolyte imbalances.
- D. Insufficient oxygen reaching the heart muscle.
Correct Answer: D
Rationale: MI pain results from myocardial ischemia due to insufficient oxygen delivery to the heart muscle, caused by coronary artery occlusion.
A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior is probably caused by:
- A. Uncertainty and an underlying fear of recurrence.
- B. The usual trajectory of a short-term illness.
- C. A history of a behavioral illness.
- D. The one-time crisis from learning of the diagnosis.
Correct Answer: A
Rationale: Disruptive behavior in a cancer client is often driven by uncertainty and fear of recurrence, reflecting ongoing emotional distress.