Nokea
The nurse explains to the client with Hodgkin's disease that a bone marrow biopsy will be taken after the aspiration. What should the nurse explain about the biopsy?
- A. Your biopsy will be performed before the aspiration because enough tissue may be obtained so that you won't have to go through the aspiration.'
- B. You will feel a pressure sensation when the biopsy is taken but should not feel actual pain; if you do, tell the doctor so that you can be given extra numbing medicine.'
- C. You may hear a crunch as the needle passes through the bone, but when the biopsy is taken, you will feel a suction-type pain that will last for just a moment.'
- D. You will be shaved and cleaned with an antiseptic agent, after which the doctor will inject a needle without making an incision to aspirate out the bone marrow.'
Correct Answer: B
Rationale: During a bone marrow biopsy, the client feels pressure but should not experience pain due to local anesthesia. The nurse should instruct the client to report pain for additional anesthesia. The biopsy follows the aspiration, no crunch or suction pain is typical, and an incision may be made for the biopsy, not just aspiration.
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Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician?
- A. A change in the pattern of her pain.
- B. Pain during sexual activity.
- C. Pain during an argument with her husband.
- D. Pain during or after an activity such as lawn-mowing.
Correct Answer: A
Rationale: A change in the pattern of angina pain may indicate worsening ischemia or progression to unstable angina or MI, requiring immediate medical attention.
The nurse is caring for a client with a new colostomy and notices the client is reluctant to participate in self-care. Which intervention should the nurse implement first?
- A. Teach the client's family to perform colostomy care.
- B. Refer the client to a support group.
- C. Assess the client's barriers to self-care.
- D. Provide written instructions for colostomy care.
Correct Answer: C
Rationale: Assessing the client's barriers to self-care is the first step to understand and address their reluctance, enabling tailored interventions. Teaching family, referring to a support group, or providing instructions are secondary after identifying the underlying issues. CN: Psychosocial adaptation; CL: Synthesize
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
- A. Stage I pressure ulcer.
- B. Stage II pressure ulcer.
- C. Stage III pressure ulcer.
- D. Stage IV pressure ulcer.
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply.
- A. Angel food cake.
- B. Banana.
- C. Dried fruit.
- D. Orange juice.
- E. Peppers.
Correct Answer: B,C,D
Rationale: Loop diuretics like furosemide cause potassium loss. Bananas (B), dried fruit (C), and orange juice (D) are potassium-rich, helping prevent hypokalemia.
Before surgery for a known aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for:
- A. Low blood pressure
- B. Anxiety
- C. Headache
- D. Disorientation
Correct Answer: D
Rationale: Widening pulse pressure and aortic arch involvement in an aortic aneurysm suggest possible dissection affecting cerebral perfusion (e.g., carotid artery involvement), leading to disorientation or neurologic changes. Low blood pressure, anxiety, and headache are less specific or unrelated.