Nokea
Which of the ff are the most significant symptoms of Hodgkin’s disease category B? Choose all that apply
- A. Fever
- B. Anemia
- C. Night sweats
- D. Thrombocytopenia
Correct Answer: C
Rationale: The correct answer is C: Night sweats. In Hodgkin's disease category B, the presence of night sweats signifies more advanced disease and higher tumor burden. Night sweats are a B-symptom, along with fever and weight loss, indicating systemic symptoms. Anemia (choice B) and thrombocytopenia (choice D) are not specific to Hodgkin's disease category B and can be present in various other conditions. Fever (choice A) is not exclusive to Hodgkin's disease category B and can occur in many infections and inflammatory conditions. Night sweats are specifically associated with Hodgkin's disease and are a key indicator of disease severity in this context.
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Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain
- A. 1, 2, 3, 4
- B. 3, 4, 1, 2
- C. 2, 3, 4, 1
- D. 4, 1, 2, 3
Correct Answer: C
Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.
The nurse evaluates a certified nursing assistant. Which of the following actions by the CAN demonstrates understanding of standard precautions?
- A. Wears gloves during all client contact
- B. Cleans blood spills with soap and water
- C. Pours bulk blood and other secretions down a drain connected to a sanitary sewer
- D. Carries blood sample to the lab in an open basket
Correct Answer: A
Rationale: The correct answer is A because wearing gloves during all client contact is a key practice in standard precautions to prevent the spread of infection. Gloves act as a barrier to protect both the healthcare worker and the patient from potential pathogens. Choice B is incorrect as cleaning blood spills with soap and water is not sufficient for infection control. Choice C is incorrect because pouring bulk blood and secretions down a drain is a violation of biohazard disposal protocols. Choice D is incorrect as carrying a blood sample in an open basket can lead to potential exposure to bloodborne pathogens.
An adult has been stung by a bee and is in anaphylactic shock. An epinephrine (adrenaline) injection has been given. The nurse would expect which the following if the injection has been effective?
- A. The client’s breathing will become easier
- B. The client’s blood pressure will decrease
- C. There will be an increase in angiodema
- D. There will be a decrease in the client’s level of consciousness
Correct Answer: A
Rationale: The correct answer is A: The client’s breathing will become easier. Epinephrine is the first-line treatment for anaphylaxis as it helps to reverse the severe respiratory symptoms. By administering epinephrine, it causes bronchodilation, which helps improve breathing by opening up the airways. Choices B, C, and D are incorrect. B is incorrect because epinephrine typically causes an increase in blood pressure due to its vasoconstrictive effects. C is incorrect because angioedema is a potential side effect of anaphylaxis and would not be expected to increase after epinephrine administration. D is incorrect because epinephrine helps to improve alertness and consciousness by increasing blood flow to the brain.
Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
- A. "What would you like to do first, brush your teeth?"
- B. "Where is y our toothbrush?"
- C. "When would you like to have your bath?"
- D. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
Correct Answer: D
Rationale: The correct answer is D because it offers the patient autonomy by providing a choice between brushing their teeth independently or having assistance. This empowers the patient to make decisions regarding their personal hygiene, promoting independence and self-esteem. Choice A does not offer a choice or empower the patient. Choice B focuses solely on the location of the toothbrush and does not address the patient's needs. Choice C does not provide the patient with a sense of control over their hygiene routine. By contrast, choice D acknowledges the patient's needs, offers a choice, and encourages independence.
Which of the following outcomes is correctly written?
- A. Abdominal incision will show no signs of infection.
- B. On discharge, client will be free of infection.
- C. On discharge, client will be able to list five symptoms of infection.
- D. During home care, nurse will not observe symptoms of infection.
Correct Answer: C
Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.