Nokea
Which of the ff instructions should a nurse give a client with non-Hodgkin’s lymphoma who is being treated with radiation and chemotherapy?
- A. Increase fluid intake
- B. Intake low-fat meals
- C. Intake soft, bland foods
- D. Intake food rich in folic acid
Correct Answer: A
Rationale: The correct answer is A: Increase fluid intake. This is important for a client undergoing radiation and chemotherapy for non-Hodgkin's lymphoma to prevent dehydration, help flush out toxins, and support kidney function. Increasing fluid intake can also help manage side effects like nausea and vomiting. Choices B, C, and D are incorrect because low-fat meals, soft bland foods, and foods rich in folic acid are not specifically indicated for clients undergoing radiation and chemotherapy for non-Hodgkin's lymphoma.
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A client is receiving chemotherapy to treat breath cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy?
- A. A Urine output of 400 ml in 8 hours
- B. B. Serum potassium level of 3.6 mEq/L
- C. C. Blood pressure of 120/64 to 130/72 mm Hg
- D. D. Dry oral mucous membranes and cracked lips
Correct Answer: A
Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances.
Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range. Choice C is incorrect as the blood pressure readings provided are within the normal range. Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.
Which of the following groups of terms best describes a nurse-initiated intervention?
- A. Dependent, physician-ordered, recovery
- B. Autonomous, clinical judgment, client outcomes
- C. Medical diagnosis, medication administration
- D. Other health care providers, skill acquisition
Correct Answer: B
Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.
The nurse assesses for the characteristic movement of Parkinson’s disease which is a (n):
- A. Exaggerated muscle flaccidity that leads to frequent falls
- B. Hyperextension of the back and neck that alters normal movements
- C. Pronation- supination of the hand and forearm that interferes with normal hand activities
- D. Combination of all of the above
Correct Answer: C
Rationale: The correct answer is C because pronation-supination of the hand and forearm is a characteristic movement in Parkinson's disease called "pill-rolling tremor." This movement interferes with normal hand activities due to involuntary shaking.
A is incorrect because exaggerated muscle flaccidity does not lead to frequent falls in Parkinson's disease. B is incorrect as hyperextension of the back and neck is not a characteristic movement of Parkinson's disease. D is incorrect as it combines all options, which is not accurate.
The primary underlying disorder of pulmonary edema is:
- A. Decreased left ventricular pumping
- B. Increased left atrial contractility
- C. Decreased right ventricular elasticity
- D. Increased right atrial pressure
Correct Answer: A
Rationale: Step 1: Pulmonary edema is caused by fluid accumulation in the lungs due to increased pressure in the pulmonary vasculature.
Step 2: Decreased left ventricular pumping leads to congestive heart failure, causing increased pressure in pulmonary circulation.
Step 3: This increased pressure forces fluid from the capillaries into the alveoli, causing pulmonary edema.
Step 4: Increased left atrial contractility (B) would not directly lead to pulmonary edema.
Step 5: Decreased right ventricular elasticity (C) and increased right atrial pressure (D) are not directly related to the pathophysiology of pulmonary edema.
Summary: The correct answer is A because decreased left ventricular pumping directly contributes to the increased pressure in the pulmonary circulation that leads to pulmonary edema. Choices B, C, and D do not align with the primary underlying disorder of pulmonary edema.
A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?
- A. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”
- B. “If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar.”
- C. “I will have to monitor my blood glucose level closely and notify the physician if it’s constantly elevated.”
- D. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.”
Correct Answer: A
Rationale: The correct answer is A because it demonstrates an understanding of the key factors in managing hyperosmolar hyperglycemic nonketotic syndrome (HHNS), which include avoiding dehydration and being aware of changes in urination, thirst, and hunger. This statement shows awareness of the importance of maintaining hydration and recognizing early signs of worsening symptoms.
Choice B is incorrect as consuming sugary soda can exacerbate the condition by further increasing blood sugar levels. Choice C is incorrect because while monitoring blood glucose levels is important, it is not the primary method of preventing HHNS. Choice D is incorrect because consuming high-carbohydrate snacks can contribute to elevated blood glucose levels, which is counterproductive in managing HHNS.