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The nurse devises a teaching plan for the client with aplastic anemia. Which of the following is the most important concept to teach for health promotion and maintenance?
- A. Eat animal protein and dark green, leafy vegetables and eggs.
- B. Avoid exposure to others with acute infections.
- C. Practice yoga and meditation to decrease stress and anxiety.
- D. Get 8 hours of sleep at night and take naps during the day.
Correct Answer: B
Rationale: Aplastic anemia is characterized by bone marrow failure, leading to low blood cell counts and increased risk of infection due to neutropenia. The most important health promotion strategy is to avoid exposure to infections, as infections can be life-threatening in these clients. While nutrition, stress management, and sleep are important, infection prevention is the priority.
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When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle?
- A. Dysmenorrhea.
- B. Metrorrhagia.
- C. Oligomenorrhea.
- D. Menorrhagia.
Correct Answer: C
Rationale: Thyrotoxicosis increases metabolism, which can lead to decreased menstrual flow or oligomenorrhea (infrequent menstruation). Dysmenorrhea (painful periods), metrorrhagia (irregular bleeding), and menorrhagia (heavy bleeding) are less commonly associated with thyrotoxicosis.
Which of the following physical assessment findings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)?
- A. Increased anteroposterior chest diameter.
- B. Underdeveloped neck muscles.
- C. Collapsed neck veins.
- D. Increased chest excursions with respiration.
Correct Answer: A
Rationale: Advanced COPD causes air trapping, increasing anteroposterior chest diameter (barrel chest). Neck muscles may hypertrophy from respiratory effort. Neck veins may distend, and chest excursions decrease due to lung hyperinflation.
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Encourage the client to cough and deep breathe.
- C. Auscultate the lungs to detect abnormal breath sounds.
- D. Contact the physician.
Correct Answer: D
Rationale: Sudden dyspnea, tachypnea, and chest discomfort suggest a pulmonary embolism, a medical emergency. Contacting the physician first ensures rapid intervention. Elevating the bed, encouraging coughing, or auscultating lungs delays critical treatment.
A client who has undergone a mastectomy is worried about her body image and its impact on her sexual relationship. The nurse should suggest:
- A. Wearing a prosthesis during intimate moments.
- B. Avoiding discussions about her surgery with her partner.
- C. Focusing only on non-physical aspects of intimacy.
- D. Ignoring her concerns as they are temporary.
Correct Answer: A
Rationale: Wearing a prosthesis can help the client feel more confident about her body image during intimate moments, supporting her sexual relationship.
The nurse has attended a staff development conference regarding patient-controlled analgesia. Which of the following statements by the nurse indicates effective understanding?
- A. A client may be prescribed a loading dose before they are able to activate their own prescribed dosage.
- B. PCAs are not recommended for individuals with acute pain.
- C. PCAs decrease the need for a client to have pain assessments.
- D. When a client receives a PCA via a continuous basal rate, it decreases their risk for adverse effects.
Correct Answer: A
Rationale: A loading dose is often used in PCA to achieve initial pain control before the patient begins self-administering doses. PCAs are suitable for acute pain, do not eliminate the need for pain assessments, and continuous basal rates may increase adverse effect risks.