Nokea
When assessing the client with Hodgkin's disease, the nurse should observe the client for which of the following?
- A. Herpes zoster infections.
- B. Discolored teeth.
- C. Hemorrhage.
- D. Hypercellular immunity.
Correct Answer: A
Rationale: Hodgkin's disease impairs immune function, increasing the risk of infections like herpes zoster (shingles). Discolored teeth, hemorrhage, and hypercellular immunity are not typical findings.
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The nurse has provided medication instructions to a client who has been prescribed a fentanyl transdermal patch. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply.
- A. I may still need pain medication while this patch is applied.
- B. If the patch comes loose, I may reinforce it with a piece of tape.
- C. I can apply heat to the patch site to increase the pain relief.
- D. I should remove this patch while I am sleeping.
- E. The patch will need to be changed every 72 hours.
Correct Answer: A,B,E
Rationale: A: Breakthrough pain may require additional medication. B: Taping a loose patch is acceptable. E: Fentanyl patches are typically changed every 72 hours. C is incorrect because heat can increase absorption and risk toxicity. D is incorrect as patches are not removed during sleep.
A client with leukemia is admitted with a white blood cell count of 2,000/mm³ and a fever of 101.8°F (38.8°C). The nurse should initiate:
- A. Contact precautions.
- B. Reverse isolation.
- C. Standard precautions.
- D. Droplet precautions.
Correct Answer: B
Rationale: A low white blood cell count (2,000/mm³) with fever indicates neutropenia and high infection risk, necessitating reverse isolation to protect the client from pathogens.
The expected outcome of using miotics to treat glaucoma is:
- A. Paralyzing ciliary muscles.
- B. Constricting intraocular vessels.
- C. Constricting the pupil.
- D. Relaxing ciliary muscles.
Correct Answer: C
Rationale: Miotics (e.g., pilocarpine) constrict the pupil, which opens the drainage angle of the eye, facilitating aqueous humor outflow and reducing intraocular pressure.
The nurse is teaching the client how to care for her ileostomy. The client asks the nurse how long she can wear her pouch before changing it. The nurse responds:
- A. The pouch is changed only when it leaks.
- B. You can wear the pouch for about 4 to 7 days.
- C. You can wear the pouch for about 4 to 7 days.
- D. It depends on your activity level and your diet.
Correct Answer: B
Rationale: An ileostomy pouch is typically worn for 4 to 7 days unless it leaks or causes skin irritation, providing a standard guideline for routine changes. Activity level and diet may influence output but are not the primary determinants for pouch change frequency. CN: Physiological adaptation; CL: Synthesize
The nurse formulates a nursing diagnosis of Spiritual distress related to advanced cancer disease. An appropriate goal for the client would be to:
- A. Start attending church or chapel services once a week.
- B. Call a chaplain and set up an appointment for spiritual guidance.
- C. Reflect on past accomplishments.
- D. Participate in spiritual activities of the client's choice.
Correct Answer: D
Rationale: Participating in spiritual activities of the client's choice respects their individual beliefs and supports resolution of spiritual distress.