Nokea
Which is the primary goal of care for a client diagnosed with sickle cell anemia?
- A. The client will call the HCP if feeling ill.
- B. The client will be compliant with medical regimen.
- C. The client will live as normal a life as possible.
- D. The client will verbalize understanding of treatments.
Correct Answer: C
Rationale: The primary goal for SCA is to live normally (C), managing crises. Calling HCP (A), compliance (B), and understanding (D) are secondary.
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A 5-year-old boy is admitted because he bled profusely when he lost his first baby tooth. After a workup, he is diagnosed as having classic hemophilia. His mother asks the nurse if his two younger sisters will also develop hemophilia. What is the best answer for the nurse to give?
- A. They will not develop the disease.'
- B. Statistically, one of them is likely to develop the disease.'
- C. They are not likely to get the disease, but they may be carriers.'
- D. If it doesn't show up by the time they start school, they are unlikely to develop the condition.'
Correct Answer: C
Rationale: Hemophilia is an X-linked recessive disorder. Females are unlikely to develop the disease but may be carriers, especially if the mother is a carrier.
The nurse writes a diagnosis of 'activity intolerance' for a client diagnosed with anemia. Which intervention should the nurse implement?
- A. Encourage isometric exercises.
- B. Assist the client with activities of daily living (ADLs).
- C. Provide a high-protein diet.
- D. Refer to the physical therapist.
Correct Answer: B
Rationale: Assisting with ADLs (B) conserves energy in anemia-related activity intolerance. Isometric exercises (A) strain oxygen capacity, diet (C) is medical, and PT (D) is collaborative.
The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis?
- A. Fever and infections.
- B. Nausea and vomiting.
- C. Excessive energy and high platelet counts.
- D. Cervical lymph node enlargement and positive acid-fast bacillus.
Correct Answer: A
Rationale: AML causes neutropenia, leading to fever/infections (A). Nausea (B) is nonspecific, high platelets/energy (C) are incorrect (AML causes thrombocytopenia/fatigue), and acid-fast bacillus (D) indicates TB, not AML.
The female client, who has Hodgkin’s lymphoma with cervical and axillary node involvement, is to receive chemotherapy and radiation. The nurse evaluates that the client is coping positively when the client makes which statement?
- A. “I’ve a wig that matches my hair color, but I’ll miss my own hair.”
- B. “I am so glad that the treatments won’t cause me to lose my hair.”
- C. “I’m happy that the drug-radiation combination prevents mucositis.”
- D. “I’ve faith that my doctor will cure me and I’ll never have cancer again.”
Correct Answer: A
Rationale: A. The client is expressing feelings about hair loss but has acted positively related to her feelings and obtained a wig. This statement indicates positive coping. B. This statement reflects that either the client is in denial or is uninformed regarding the effects of chemotherapy and radiation treatments. Chemotherapy and radiation will involve the cervical lymph nodes; side effects will include alopecia. C. Chemotherapy and radiation will involve the cervical lymph nodes; side effects will include mucositis. D. The risk for other cancers is increased after chemotherapy and radiation for Hodgkin’s lymphoma, so long-term surveillance is crucial.
The client is placed on neutropenia precautions. Which information should the nurse teach the client?
- A. Shave with an electric razor and use a soft toothbrush.
- B. Eat plenty of fresh fruits and vegetables.
- C. Perform perineal care after every bowel movement.
- D. Some blood in the urine is not unusual.
Correct Answer: A
Rationale: Neutropenia precautions include electric razors and soft toothbrushes (A) to prevent bleeding/infection. Fresh produce (B) risks infection, perineal care (C) is routine, and hematuria (D) is abnormal.