Nokea
What are the nursing interventions for a client with thalassemia?
- A. Maintain the client on bed rest and protect him or her from infections
- B. Ambulate the client frequently
- C. Advise drinking 3 quarts (L) of fluid per day
- D. Instruct the client to elevate the lower extremities as much as possible
Correct Answer: A
Rationale: The correct answer is A because thalassemia is a genetic blood disorder that can cause anemia and fatigue. By maintaining the client on bed rest and protecting them from infections, we can help prevent complications such as fatigue and infections due to reduced red blood cell production. Ambulating the client frequently (choice B) may lead to increased fatigue and risk of injury. Advising to drink 3 quarts of fluid per day (choice C) is not specific to thalassemia treatment and could potentially worsen symptoms. Instructing the client to elevate lower extremities (choice D) is not directly related to managing thalassemia and may not provide significant benefits in this context.
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A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client’s history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:
- A. Testosterone therapy during childhood
- B. Early onset of puberty
- C. Sexually transmitted disease
- D. Cryptorchidism
Correct Answer: D
Rationale: The correct answer is D: Cryptorchidism. Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer as the testicle does not descend into the scrotum during fetal development, increasing the risk of cancer development. Testosterone therapy during childhood (A) and early onset of puberty (B) are not directly linked to testicular cancer. Sexually transmitted diseases (C) typically do not increase the risk of testicular cancer. Therefore, choice D is the most relevant risk factor for testicular cancer in this scenario.
An adult is being taught about a healthy diet. How can the food pyramid help guide the client on his diet?
- A. By indicating exactly how many servings of each group to eat
- B. By calculating how many calories the client should have
- C. By suggesting daily food choices
- D. By dividing the food into four basic groups
Correct Answer: C
Rationale: The correct answer is C: By suggesting daily food choices. The food pyramid helps guide a client's diet by recommending the types and proportions of food to consume daily, such as fruits, vegetables, grains, protein, and dairy. It does not specify exact servings (A), calculate calories (B), or divide food into only four basic groups (D). The pyramid is a visual representation of a balanced diet, emphasizing variety and moderation.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: The correct answer is C because it is essential for the nurse to ensure accurate and up-to-date vital signs before administering medications. By asking the NAP to record the patient's vital signs, the nurse can make informed decisions about the patient's condition and prevent any potential complications.
Choice A is incorrect because administering medications without knowing the patient's vital signs, particularly if they are abnormal, can be dangerous. Choice B is not the best course of action as it delays the crucial step of obtaining the vital signs. Choice D is incorrect as omitting vital signs without assessment could compromise patient safety. Therefore, choice C is the most appropriate response to ensure patient well-being and medication safety.
Nurse Melanie is teaching an adult class about the different types of hepatitis. Which statement does not pertain to hepatitis A?
- A. “Is caused by an RNA virus of the enterovirus family.”
- B. “It spreads primarily by fecal-oral route, usually through the ingestion of infcetd food or liquids.”
- C. “It may not be spread from sexual contact.”
- D. “Type A hepatitis occurs worldwide, especially in areas with overcrowding and poor sanitation.”
Correct Answer: A
Rationale: The correct answer is A because hepatitis A is caused by a virus from the Picornaviridae family, not the enterovirus family. Hepatitis A spreads through contaminated food or water, not through sexual contact. It is true that hepatitis A occurs worldwide in areas with poor sanitation, but the virus is not from the enterovirus family. Choices B, C, and D are incorrect because they all pertain to hepatitis A characteristics.
A patient’s chest x-ray examination indicates fluid in both lung bases. Which of the ff. signs or symptoms present during the nurse’s assessment most reflects these x-ray examination findings?
- A. Fatigue
- B. Peripheral edema
- C. Bilateral crackles
- D. Jugular vein distention
Correct Answer: C
Rationale: The correct answer is C, bilateral crackles. Fluid in both lung bases on x-ray indicates pulmonary edema, causing crackles on auscultation. Fatigue (A) is a nonspecific symptom. Peripheral edema (B) is a sign of fluid retention in the extremities, not lungs. Jugular vein distention (D) indicates increased central venous pressure, which is not specific to lung fluid.