Nokea
Which of the following activities indicates that the client with cancer is adapting well to body image changes?
- A. The client names his brother as the person to call if he is experiencing suicidal ideation.
- B. The client discusses changes in body structure and function.
- C. The client discusses the date of his return to work.
- D. The client serves as a volunteer in a client-to-client visitation program.
Correct Answer: D
Rationale: Volunteering in a client-to-client program indicates positive adaptation to body image changes, as it reflects confidence and engagement with others despite physical changes.
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What should the nurse include in the care plan for a client with a spinal cord injury?
- A. Frequent repositioning.
- B. High-protein diet.
- C. Limited mobility exercises.
- D. Fluid restriction.
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers in clients with spinal cord injuries.
During preadmission testing for same-day surgery, a client states that she has added two cloves of garlic each day to her diet to help control her blood pressure. The nurse should further inquire about which of the following?
- A. The type of surgery the client is having.
- B. What her blood pressure has been running.
- C. The amount of garlic she is eating.
- D. Her preference for the type of anesthesia.
Correct Answer: B
Rationale: Garlic can affect blood pressure and has anticoagulant properties, which may increase bleeding risk during surgery. Inquiring about the client's blood pressure helps assess the impact of garlic on her condition and informs surgical planning. The type of surgery, amount of garlic, or anesthesia preference are less directly relevant to this concern.
When performing the Heimlich maneuver on a conscious adult victim, the rescuer delivers inward and upward thrusts specifically:
- A. Above the umbilicus.
- B. At the level of the xiphoid process.
- C. Over the victim's midabdominal area.
- D. Below the xiphoid process and above the umbilicus.
Correct Answer: D
Rationale: The Heimlich maneuver involves thrusts below the xiphoid process and above the umbilicus to safely dislodge a foreign body without injuring internal organs.
Which factor besides the degree of neutropenia does the nurse assess in determining the client's risk of infection?
- A. Length of time neutropenia has existed.
- B. Health status before neutropenia.
- C. Body build and weight.
- D. Resistance to infection in childhood.
Correct Answer: A
Rationale: The duration of neutropenia significantly affects infection risk, as prolonged neutropenia increases exposure to pathogens. Pre-existing health status, body build, and childhood resistance are less directly relevant to current infection risk.
When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
- A. Drug-induced hemolytic anemia.
- B. Purpura.
- C. Infectious emboli.
- D. Ecchymosis.
Correct Answer: A
Rationale: Cephalosporins can rarely cause drug-induced hemolytic anemia by triggering an immune response that destroys red blood cells. The nurse should monitor for signs such as jaundice, dark urine, or a drop in hemoglobin. Purpura, infectious emboli, and ecchymosis are not commonly associated with cephalosporin use.