Nokea
The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that:
- A. Alopecia is an unavoidable side effect.
- B. There are several wig makers for children.
- C. Most children select a favorite hat to protect their heads.
- D. His hair will grow back in a few months.
Correct Answer: D
Rationale: Alopecia has occurred, and knowing it is a side effect does not address their concern. Although true, it does not give them hope for the future. Although true, it does not provide them with information of the temporary nature of the situation. Knowing the hair will grow back provides comfort that the alopecia is temporary.
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A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
- A. Depression
- B. Agitation
- C. Psychotic ideation
- D. Anhedonia
Correct Answer: B
Rationale: Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. These clinical features are classic signs of agitation. Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. Anhedonia is the inability to experience pleasure.
The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find:
- A. Irregular movement of the wrist
- B. Enlargement of the breasts
- C. Dilated veins around the umbilicus
- D. Redness of the palmar surfaces
Correct Answer: A
Rationale: Asterixis, a flapping tremor of the wrists when extended, is a sign of hepatic encephalopathy in cirrhosis due to ammonia buildup. The other findings are unrelated to asterixis.
Which of the following statements applies to the care of the client hospitalized with influenza?
- A. The nurse should wear an N-95 mask when caring for the client.
- B. The client may cohort with another client hospitalized with the same diagnosis.
- C. Equipment used in the client's care should remain in the room until the client is discharged.
- D. The door to the client's room may remain open to the hallway.
- E. The nurse should wear a mask when direct care of the client is required.
Correct Answer: B, C, E
Rationale: Influenza requires droplet precautions: cohorting with same diagnosis (B), keeping equipment in the room (C), and wearing a mask for direct care (E). N-95 masks (A) are for airborne diseases (e.g., TB). The door should remain closed (D) to limit droplet spread.
The client is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test?
- A. Creatine kinase
- B. Ammonia
- C. Myoglobin
- D. Troponin T
- E. Gamma-glutamyl transferase
- F. Bilirubin
Correct Answer: A, C, D
Rationale: Creatine kinase (A), myoglobin (C), and troponin T (D) are cardiac biomarkers elevated in myocardial infarction. Ammonia (B), gamma-glutamyl transferase (E), and bilirubin (F) are unrelated to acute cardiac events.
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring for anemia
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, so monitoring for anemia is the priority.