Nokea
The nurse is caring for the client experiencing superior vena cava syndrome secondary to lung cancer. Which problem should be the nurse’s priority?
- A. Ineffective breathing pattern
- B. Ineffective tissue perfusion
- C. Risk for infection
- D. Impaired skin integrity
Correct Answer: A
Rationale: A. Ineffective breathing pattern occurs with superior vena cava syndrome because the superior vena cava is located next to the main stem bronchus and causes compression of the intrathoracic structures. B. Ineffective tissue perfusion may occur with superior vena cava syndrome, but ineffective breathing pattern is priority. C. Risk for infection occurs with chemotherapy treatment and not from superior vena cava syndrome. D. Impaired skin integrity occurs with malignant skin conditions and usually not from lung cancer.
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The nurse is caring for the client following a total laryngectomy for treatment of laryngeal cancer. The nurse should plan consultations with which members of the multidisciplinary team?
- A. Physical therapist
- B. Dietitian
- C. Speech therapist
- D. Dentist
- E. Occupational therapist
- F. Social worker
Correct Answer: A, B, C, F
Rationale: Total laryngectomy is removal of the entire larynx as well as the hyoid bone, the true vocal cords, the false vocal cords, the epiglottis, the cricoid cartilage, and two to three tracheal rings. The physical therapist is needed for neck exercises. B. The dietitian is needed to ensure adequacy of oral intake. C. The speech therapist is needed for other forms of communication and swallowing. D. The dentist is not routinely consulted when caring for a laryngectomy client. E. An occupational therapist is not routinely consulted when caring for a laryngectomy client. F. The social worker is needed for contact with outside resources to assist the client in ongoing needs.
The nurse is planning the care of a client diagnosed with aplastic anemia. Which interventions should be taught to the client? Select all that apply.
- A. Avoid alcohol.
- B. Pace activities.
- C. Stop smoking.
- D. Eat a balanced diet.
- E. Use a safety razor.
Correct Answer: A,B,C,D
Rationale: Avoiding alcohol (A), pacing activities (B), stopping smoking (C), and balanced diet (D) support aplastic anemia management. Safety razors (E) risk bleeding due to thrombocytopenia.
The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention?
- A. T 99, P 102, R 22, and BP 132/68.
- B. Hyperplasia of the gums.
- C. Weakness and fatigue.
- D. Pain in the left upper quadrant.
Correct Answer: D
Rationale: Left upper quadrant pain (D) suggests splenic rupture, a life-threatening AML complication. Vitals (A) are stable, gum hyperplasia (B) is expected, and fatigue (C) is common.
The nurse writes the problem of 'grieving' for a client diagnosed with non-Hodgkin's lymphoma. Which collaborative intervention should be included in the plan of care?
- A. Encourage the client to talk about feelings of loss.
- B. Arrange for the family to plan a memorable outing.
- C. Refer the client to the American Cancer Society’s Dialogue group.
- D. Have the chaplain visit with the client.
Correct Answer: C
Rationale: Grieving requires collaborative support; ACS Dialogue group (C) provides peer support. Talking (A) is independent, outings (B) are nonspecific, and chaplain visits (D) are spiritual, not primary.
The unlicensed assistive personnel (UAP) asks the primary nurse, 'How does someone get hemophilia A?' Which statement would be the primary nurse’s best response?
- A. It is an inherited X-linked recessive disorder.'
- B. There is a deficiency of the clotting factor VIII.'
- C. The person is born with hemophilia A.'
- D. The mother carries the gene and gives it to the son.'
Correct Answer: A
Rationale: Hemophilia A is an X-linked recessive disorder (A), the most precise explanation. Factor VIII deficiency (B) is a result, born with it (C) is vague, and mother-to-son (D) is partial.