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The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.” DISTURBANCES IN IMMUNOLOGIC FUNCTIONING
Correct Answer: E
Rationale: I'm sorry, but it seems like the correct answer (E) is missing from the question. Could you please provide the correct answer so that I can provide you with a detailed explanation of why it is correct and summarize why the other choices are incorrect?
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A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. Soap can irritate the skin and exacerbate the risk for impaired skin integrity in a client receiving radiation therapy. By avoiding soap, we minimize the risk of skin breakdown and promote skin healing.
B: Applying talcum powder can actually worsen skin irritation and should be avoided.
C: Wearing a lead apron is not relevant to the nursing diagnosis of risk for impaired skin integrity.
D: Removing thoracic skin markings is not necessary for skin integrity and may disrupt the treatment plan.
The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?
- A. Clarify discrepancies of assessment data with the client.
- B. Validate client data with members of the health care team.
- C. Document all data collected in the nursing history and physical examination.
- D. Seek input from family members regarding the client’s breathing at home.
Correct Answer: A
Rationale: Step-by-step rationale:
1. The nurse should clarify discrepancies of assessment data with the client to ensure accurate information.
2. The client's denial of breathing problems conflicts with physical signs, indicating a potential lack of awareness or reluctance to disclose symptoms.
3. By clarifying with the client, the nurse can address any misunderstandings or encourage honest communication.
4. This approach promotes client-centered care and ensures a comprehensive understanding of the client's health status.
Summary:
- Choice A is correct as it addresses the need to clarify discrepancies with the client for accurate assessment.
- Choice B is incorrect as validation with the healthcare team may not provide insight into the client's perception.
- Choice C is incorrect as it does not address the need to resolve conflicting assessment data.
- Choice D is incorrect as family input may not provide accurate information if the client denies symptoms.
Nurse Karen is caring for a client with chronic renal failure. Which is a correct intervention for hyperkalemia?
- A. assess patient for fever and chest pain
- B. assess patient for muscle weakness, diarrhea and ECG changes
- C. encourage compliance with fluid restriction
- D. prepare patient for cardiac ultrasound
Correct Answer: B
Rationale: The correct answer is B because hyperkalemia presents with symptoms such as muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common sign due to potassium's effect on neuromuscular function. Diarrhea can lead to potassium loss. ECG changes, such as peaked T waves and widened QRS complexes, indicate cardiac involvement. Assessing for these symptoms helps monitor the severity of hyperkalemia and guide treatment. Other choices are incorrect because assessing for fever and chest pain (choice A) are not specific to hyperkalemia. Encouraging fluid restriction (choice C) may not directly address hyperkalemia. Preparing for a cardiac ultrasound (choice D) is not an immediate intervention for hyperkalemia.
At a public health fair, a nurse discusses the dangers of sun exposure. Prolonged sun exposure has been blamed for which form of cancer?
- A. Malignant melanoma
- B. Basal cell epithelioma
- C. Squamous cell carcinoma
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Malignant melanoma, basal cell epithelioma, and squamous cell carcinoma are all forms of skin cancer associated with prolonged sun exposure. Melanoma is the deadliest form, originating in melanocytes; basal cell and squamous cell carcinomas are more common but less aggressive. All three types can develop due to cumulative UV radiation exposure. Therefore, all options are correct in this context.
The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone
- B. Observe for swelling of the neck, tracheal deviation, and severe pain
- C. Evaluate the quality of the client’s voice postoperatively, noting any dastric changes
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes
Correct Answer: D
Rationale: The correct answer is D: Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. After a thyroidectomy, the parathyroid glands may be inadvertently damaged, leading to hypocalcemia. Muscle twitching and numbness/tingling are early signs of hypocalcemia. The nurse should monitor for these symptoms to detect and address hypocalcemia promptly.
Choice A is incorrect as monitoring thyroid-stimulating hormone levels is not related to hypocalcemia. Choice B is incorrect as it describes signs of potential complications like bleeding or airway obstruction, not hypocalcemia. Choice C is incorrect as changes in voice quality and gastric issues are not specific to hypocalcemia.