Nokea
Which of the following data regarding a client with a diagnosis of colon cancer are subjective?
- A. The client’s chemotherapy causes him nausea and loss of appetite.
- B. The client became teary when his daughter from out of state came to the bedside.
- C. The client’s ileostomy put out 125 mL of effluent in the past four hours.
- D. The patient is unwilling to manipulate or empty his ostomy bag.
Correct Answer: A
Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception.
Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.
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A client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?
- A. Surgery
- B. Radiation
- C. Chemotherapy
- D. Immunotherapy
Correct Answer: A
Rationale: The correct answer is A: Surgery. Surgery is the primary treatment for vaginal cancer, especially for early-stage cases. It involves removing the cancerous tissue from the vagina. Radiation (B) and chemotherapy (C) may also be used in addition to surgery in some cases, but they are not the primary treatment. Immunotherapy (D) is not a standard treatment for vaginal cancer. It is important to prioritize surgery as it directly targets and removes the cancerous cells from the affected area, increasing the chances of successful treatment and recovery.
Postural Hypotension is A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
- A. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
- B. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
- C. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
Correct Answer: A
Rationale: The correct answer is A because postural hypotension is defined as a drop in systolic blood pressure of greater than 20 mmHg or a drop in diastolic blood pressure of greater than 10 mmHg within 3 minutes of standing from a sitting or supine position. Therefore, a drop in systolic pressure greater than 10 mmHg when changing from lying to sitting is indicative of postural hypotension.
Choice B is incorrect as postural hypotension is primarily defined by changes in systolic blood pressure, not diastolic. Choice C is incorrect because a drop in diastolic pressure greater than 10 mmHg is not the defining characteristic of postural hypotension. Choice D is not provided.
The most likely cause of her chief complaint this morning is
- A. A decrease in postoperative stress causing poiyuria
- B. The onset of diabetes mellitus, an unusual complication
- C. An expected result of the removal of the pituitary gland
- D. A frequent complication of the hypophysectomy
Correct Answer: D
Rationale: The correct answer is D because polyuria is a common complication of hypophysectomy, the surgical removal of the pituitary gland. The pituitary gland plays a crucial role in regulating water balance in the body, and its removal can lead to excessive urine production. Choices A, B, and C are incorrect because a decrease in stress does not typically cause polyuria, diabetes mellitus is not an immediate complication of surgery, and polyuria is not an expected result of pituitary gland removal.
Which of the ff. positions is best for a chest drainage system when the patient is being transported by wheelchair?
- A. Hang it on the top of the wheelchair backrest.
- B. Place it on the patient’s feet and ask the patient to hold it.
- C. Hang it on the same pole as the patient’s IV.
- D. Place it in the patient’s lap.
Correct Answer: A
Rationale: The correct answer is A because hanging the chest drainage system on the top of the wheelchair backrest ensures that the system remains upright and secured during transportation, reducing the risk of accidental disconnection or leakage. Placing it on the patient's feet (B), hanging it with the IV pole (C), or placing it in the patient's lap (D) can lead to potential complications such as pulling or kinking the drainage tubing, increasing the risk of infection or injury to the patient.
One of the side effects of INH administration is peripheral neuropathy. To prevent this effect, Nurse Carlos teaches Andrew to:
- A. have a strict low cholesterol diet
- B. get extra bed rest
- C. supplement the diet with pyridoxine
- D. avoid excessive sun exposure
Correct Answer: C
Rationale: Step-by-step rationale:
1. INH (Isoniazid) can lead to peripheral neuropathy due to vitamin B6 deficiency.
2. Pyridoxine is vitamin B6, which helps prevent neuropathy.
3. Supplementing with pyridoxine can counteract the deficiency caused by INH.
4. Thus, option C, supplementing the diet with pyridoxine, is the correct choice.
Summary:
- Option A is incorrect as a low cholesterol diet does not address the vitamin B6 deficiency.
- Option B is incorrect as excessive bed rest does not prevent neuropathy.
- Option D is incorrect as sun exposure is not related to the prevention of peripheral neuropathy.