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Which of the ff is the primary sign of breast cancer?
- A. A bloody discharge from the nipple
- B. A retraction of the nipple
- C. A dimpling of the skin over the lesion
- D. A painless mass in the breast CLIENT IN BIOLOGICAL CRISIS MANAGEMENT of PATIENTS with COMPLICATIONS from HEART DISEASE
Correct Answer: D
Rationale: The correct answer is D: A painless mass in the breast. This is the primary sign of breast cancer because most breast cancers present as painless lumps or masses. This is due to the abnormal growth of cells forming a tumor. Other choices (A, B, C) are also signs of breast cancer, but they are not as common or primary as the presence of a painless mass. A bloody discharge from the nipple (A) can be a sign of a benign condition or cancer, but it is not the most common presentation. Nipple retraction (B) and dimpling of the skin over the lesion (C) can also be signs of breast cancer, but they usually occur in later stages of the disease. Therefore, the presence of a painless mass in the breast is the primary sign that should raise suspicion for breast cancer.
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A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drug falls into this category?
- A. Procainamide (Pronestyl)
- B. Phenytoin (Dilantin)
- C. Azathioprine (Imuran)
- D. Allopurinol (Zyloprim)
Correct Answer: B
Rationale: The correct answer is B: Phenytoin (Dilantin). Phenytoin is known to cause gingival hyperplasia as a side effect, which can be minimized with good oral hygiene practices. Procainamide, Azathioprine, and Allopurinol are not associated with gingival hyperplasia. Therefore, the client receiving cyclosporine should focus on practicing good oral hygiene specifically when taking Phenytoin to minimize the risk of developing gingival hyperplasia.
A patient is being taught the action of digoxin, which is an inotropic agent. The nurse defines an inotropic agent as a medication that has which of the following actions?
- A. Decreases heart rate
- B. Increases conduction time
- C. Increases heart rate
- D. Strengthens heart contraction
Correct Answer: D
Rationale: The correct answer is D: Strengthens heart contraction. Digoxin is an inotropic agent that works by increasing the force of the heart's contractions. This leads to improved cardiac output and helps manage conditions like heart failure. Choices A, B, and C are incorrect because digoxin does not decrease heart rate, increase conduction time, or increase heart rate. It specifically targets the strength of the heart's contractions, making option D the most appropriate choice. This action of digoxin is crucial in improving the efficiency of the heart's pumping function.
Which action by the nurse is appropriate?
- A. Observe the patient for abnormal bleeding.
- B. Notify the physician and expect an order to increase the warfarin dose.
- C. Advise the patient to double today’s dose of warfarin.
- D. Administer Vit. K per protocol.
Correct Answer: A
Rationale: The correct answer is A because observing the patient for abnormal bleeding is an appropriate action to monitor for potential complications of warfarin therapy. This aligns with the nursing role in assessing and monitoring patient responses to treatment.
B is incorrect as increasing warfarin dose without physician order can lead to adverse effects. C is incorrect as altering the dose without medical advice can be dangerous. D is incorrect as administering Vitamin K would counteract the effects of warfarin, which is used to prevent blood clotting.
Which of the ff nursing interventions ensure that a client with Hodgkin’s disease remains free of infection? Choose all that apply
- A. Apply ice to the skin for brief periods
- B. Provide cool sponge baths
- C. Practice conscientious hand washing
- D. Use cotton gloves Restrict visitors or personnel with infections from contact with the client
Correct Answer: C
Rationale: Rationale:
C: Practice conscientious hand washing is correct as it helps prevent the spread of infection. Proper hand hygiene is essential in reducing the risk of infection transmission to the client with Hodgkin's disease.
A: Apply ice to the skin for brief periods is incorrect as it does not directly relate to preventing infection in the client.
B: Provide cool sponge baths is incorrect as it mainly addresses comfort and hygiene but does not specifically target infection prevention.
D: Use cotton gloves Restrict visitors or personnel with infections from contact with the client is incorrect because while using gloves can help prevent the spread of infection, restricting visitors with infections is not under the direct control of the nurse.
Summary:
Practicing conscientious hand washing is crucial in preventing infection in a client with Hodgkin's disease, while the other choices do not directly address infection control in this context.
The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
- A. Gordon’s Functional Health Patterns
- B. Activity-exercise pattern assessment
- C. General to specific assessment
- D. Problem-oriented assessment
Correct Answer: C
Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting the assessment by examining a specific aspect (surgical dressing with drainage) and will likely proceed to gather more detailed information based on the initial findings. This approach involves moving from a broad overview to specific details, which is essential in assessing postoperative patients for complications.
A: Gordon’s Functional Health Patterns is a comprehensive assessment framework that covers various aspects of an individual's health, not specifically focusing on the progression from general to specific assessments in this situation.
B: Activity-exercise pattern assessment focuses on the patient's activity levels and exercise routines, which is not the primary focus of the scenario described.
D: Problem-oriented assessment is a method that involves identifying and addressing specific health issues or concerns, which is not the primary aim of the assessment approach used by the nurse in this scenario.