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Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
- A. I'll be flying overseas to see my son and grandchildren for the holidays
- B. I plan to do my leg exercises at least three times a week
- C. I'm going to be walking in the mall everyday to build up my strength
- D. At night when I sleep, I like to use two pillows to raise my head up CARING FOR CLIENTS FOR DISORDERS OF THE LYMPHATIC SYSTEM
Correct Answer: A
Rationale: Clients with polycythemia vera are at an increased risk for developing blood clots due to the increased thickness of their blood. Flying long distances, especially overseas, can further increase this risk. Therefore, traveling long distances by plane can be dangerous for clients with polycythemia vera. The nurse should provide instructions to the client regarding the importance of discussing travel plans with their healthcare provider to ensure appropriate measures are in place to minimize the risk of blood clots.
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A 12-year-old male adolescent, recently diagnosed with Hodgkin lymphoma, shows left cervical and supraclavicular lymph node involvement and drenching night sweats. Based on Ann Arbor Classification, the patient is classified as
- A. stage IA
- B. stage IB
- C. stage IIA
- D. stage IIB
Correct Answer: D
Rationale: Involvement of two lymph node regions above the diaphragm with systemic symptoms corresponds to stage IIB.
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
- A. Hypotension
- B. Hives or rashes
- C. Localized inflammation
- D. Cramping and vomiting
Correct Answer: B
Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.
Which of the ff is a nursing intervention when assessing clients with hypertension?
- A. The nurse takes the temperature when the client is in a standing, sitting, and then supine position
- B. The nurses teaches the client about non pharmacologic and pharmacologic methods for restoring BP
- C. The nurse takes BP in both arms when the client is in a standing, sitting, and then supine position
- D. The nurse weighs the client each morning
Correct Answer: B
Rationale: The nursing intervention of teaching the client about non-pharmacologic and pharmacologic methods for restoring blood pressure is crucial in managing hypertension. Education empowers the client to actively participate in their care and make informed decisions regarding lifestyle changes, medication adherence, and other interventions to control their blood pressure levels. By providing education on interventions such as dietary modifications, exercise, stress management, and medication use, the nurse helps the client develop a comprehensive plan to manage hypertension effectively and improve their overall health outcomes.
The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
- A. Extremities
- B. Head
- C. Eyeball
- D. Chest and nostrils A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET L
Correct Answer: D
Rationale: The best way to assess whether a patient is breathing is to observe the movement of the chest and nostrils. Chest movement indicates inhalation and exhalation, while the nostrils may flare during breathing. Observing these two areas provides a more direct and accurate assessment of breathing compared to extremities, head, or eyeball movements. By focusing on the chest and nostrils, a nurse can quickly and effectively determine if a patient is breathing adequately.
or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. "Client verbalizes feelings of anxiety."
- B. "Client doesn't guess at prognosis."
- C. "Client uses any effective method to reduce tension."
- D. "Client stops seeking information."
Correct Answer: C
Rationale: The most appropriate expected outcome for a client experiencing anxiety related to a cancer diagnosis would be "Client uses any effective method to reduce tension." This outcome focuses on the client actively managing their anxiety by utilizing various strategies to decrease tension and promote feelings of calmness. It empowers the client to take control of their anxiety and seeks to foster a sense of well-being during a difficult time. The other options do not directly address the active management of anxiety as effectively as option C.