Nokea
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.
You may also like to solve these questions
The nurse writes a client problem of 'activity intolerance' for a client diagnosed with anemia. Which intervention should the nurse implement?
- A. Pace activities according to tolerance.
- B. Provide supplements high in iron and vitamins.
- C. Administer packed red blood cells.
- D. Monitor vital signs every four (4) hours.
Correct Answer: A
Rationale: Pacing activities (A) conserves energy in anemia-related activity intolerance. Supplements (B) and transfusions (C) are medical, and vitals (D) are routine, not primary.
The client undergoing knee replacement surgery has a 'cell saver' apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system?
- A. Infuse the drainage into the client when a prescribed amount fills the chamber.
- B. Attach an hourly drainage collection bag to the unit and discard the drainage.
- C. Replace the unit with a continuous passive motion (CPM) unit and start it on low.
- D. Have another nurse verify the unit number prior to reinfusing the blood.
Correct Answer: A
Rationale: Cell saver reinfuses collected blood (A) per protocol to reduce allogeneic transfusion. Discarding (B) wastes blood, CPM (C) is unrelated, and verification (D) is for donor blood.
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.
Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply.
- A. Instruct the client to use a razor blade to shave.
- B. Avoid administering enemas to the client.
- C. Encourage participation in noncontact sports.
- D. Teach the client how to apply direct pressure if bleeding occurs.
- E. Explain the importance of not flossing the gums.
Correct Answer: B,C,D
Rationale: Avoiding enemas (B), noncontact sports (C), and teaching pressure (D) prevent bleeding in hemophilia. Razor blades (A) and avoiding flossing (E) increase bleeding risk.
The client is diagnosed with leukemia and has leukocytosis. Which laboratory value would the nurse expect to assess?
- A. An elevated hemoglobin.
- B. A decreased sedimentation rate.
- C. A decreased red cell distribution width.
- D. An elevated white blood cell count.
Correct Answer: D
Rationale: Leukocytosis in leukemia causes elevated WBCs (D). Hb (A) is low, ESR (B) is elevated, and RDW (C) is unrelated.