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The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
- A. Applies prescribed lotions to the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Wears clothing to cover the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing with antibacterial soap is too harsh for the radiation site, indicating a need for further teaching. Prescribed lotions, protective clothing, and patting to dry are appropriate.
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The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
- A. Explore changes in life that have occurred after the loss.
- B. Suggest the need for a psychiatric consultation.
- C. Offer a referral to pastoral counseling.
- D. Encourage attending a local support group.
Correct Answer: A
Rationale: Exploring life changes post-loss helps assess the client's grief and tailor interventions, making it the priority action.
The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?
- A. Five-pound (2.3 kg) weight gain.
- B. Nausea and vomiting.
- C. Short-term memory loss.
- D. Depressed affect.
Correct Answer: B
Rationale: Nausea and vomiting may indicate lithium toxicity, requiring immediate reporting. Other symptoms are concerning but less urgent.
A young adult client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
- A. The client should be aware of the signs and symptoms of his illness.
- B. The client should plan to participate in group or individual therapy while at college.
- C. Despite the illness, the client should be able to live away from home.
- D. The client's serum lithium levels should be routinely evaluated.
Correct Answer: D
Rationale: Routine monitoring of serum lithium levels is crucial to ensure therapeutic levels and prevent lithium toxicity, especially critical for a newly diagnosed client transitioning to college.
The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.
- A. Preoccupation.
- B. Reexperience.
- C. Somatization.
- D. Disorganization.
Correct Answer: C
Rationale: Somatization involves psychological distress manifesting as physical symptoms like numbness and tingling, likely due to grief. Other options are less applicable.
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?
- A. Ecchymotic blood accumulations.
- B. Evidence of patches of lost hair.
- C. Episodic complaints of pruritus.
- D. Erythema of the localized lesions.
Correct Answer: A
Rationale: Ecchymotic blood accumulations (bruises) suggest trauma or physical manipulation, indicating non-disease-related hair loss. Patches of hair loss, pruritus, or erythema could be associated with medical conditions like alopecia or inflammation.