Nokea
Which of the following clients would not be a candidate for thrombolytic therapy?
- A. Client with a pulse of 102 beats/minute
- B. Client with a blood pressure of 100/60 mm Hg
- C. Client with a history of hemorrhagic stroke one month ago
- D. Client age 65 years
Correct Answer: C
Rationale: Thrombolytics bust clots but bleed big hemorrhagic stroke history, even a month back, bans them, as re-bleed risk soars, a firm no-go. Tachycardia, low BP, or age 65 don't nix it BP's workable, age isn't a cutoff. Nurses screen this, dodging brain bleeds, a safety lock in this clot-dissolving call.
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Which statement with respect to the disadvantages of insufficient physical activity is most correct?
- A. People are not so much concerned with the disadvantages, because these will only affect them in the long run
- B. The disadvantages can be compensated by moderate eating
- C. When explained, the disadvantages are enough to motivate people to change their behaviour
- D. The disadvantages result from inadequate behavioural control (self-efficacy)
Correct Answer: A
Rationale: Inactivity's downsides long-term creep, folks shrug, not diet-fixed, rarely spur change, or just control flops. Nurses see this apathy, a chronic slow burn.
What is the essence of motivational interviewing?
- A. That change strategies must exactly match the patient's motivation
- B. That behavioural change is impossible if the patient does not want it
- C. That the counsellor motivates the patient to change and increases patient involvement
- D. That the patient's motives to show unhealthy behaviour are systematically analysed
Correct Answer: C
Rationale: Motivational interviewing counsellor sparks, pulls patients in, not rigid matches, impossibles, or motive digs. Nurses roll this, a chronic engagement art.
During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?
- A. Risk for ineffective adherence to treatment related to denial of need for chemotherapy
- B. Acute confusion related to infiltration of leukemia cells into the central nervous system
- C. Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment
- D. Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis
Correct Answer: D
Rationale: New leukemia diagnosis plus restlessness and repeat requests scream anxiety risk for ineffective health maintenance' fits, as it ties to coping, not denial , brain infiltration , or disinterest . Nurses in oncology spot this fear fogs learning, needing slower, calmer teaching to stick.
The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?
- A. A 35-yr-old patient who has wet desquamation associated with abdominal radiation
- B. A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer
- C. A 24-yr-old patient who received neck radiation and has blood oozing from the neck
- D. A 56-yr-old patient who developed a new pericardial friction rub after chest radiation
Correct Answer: C
Rationale: Neck oozing post-radiation flags carotid rupture a bleed-out risk trumping wet skin , sobs , or heart rub (D tamponade's slower). Nurses in oncology bolt here airway and blood loss kill fastest, demanding stat checks.
The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer?
- A. Teach the patient about the seven warning signs of cancer.
- B. Plan to monitor the patient's carcinoembryonic antigen (CEA) level.
- C. Teach the patient about annual chest x-rays for lung cancer screening.
- D. Discuss risks associated with cigarette smoking during each patient encounter.
Correct Answer: D
Rationale: Smoking's the lung cancer kingpin two packs a day screams risk. Hitting the patient with smoking's dangers every visit pushes primary prevention, aiming to cut exposure to tar and carcinogens fueling 85% of cases. Warning signs (CAUTION) and chest x-rays are secondary catching cancer, not stopping it. CEA's a tumor marker for tracking, not prevention. Nurses in oncology know preaching cessation at every chance leverages behavior change, the gold standard to slash lung cancer odds, trumping screening or monitoring in a heavy smoker like this.