Nokea
Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?
- A. Anemia.
- B. Osteoporosis.
- C. Weight loss.
- D. Local joint pain.
Correct Answer: D
Rationale: Local joint pain is a primary symptom of osteoarthritis, resulting from cartilage degeneration.
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The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. Which of the following describes the involvement of the disease?
- A. Involvement of a single lymph node.
- B. Involvement of two or more lymph nodes on the same side of the diaphragm.
- C. Involvement of lymph node regions on both sides of the diaphragm.
- D. Diffuse disease of one or more extralymphatic organs.
Correct Answer: A
Rationale: Stage 1A Hodgkin's disease indicates involvement of a single lymph node region without B symptoms (fever, night sweats, weight loss). Higher stages involve multiple nodes or extralymphatic sites.
The client with a laryngectomy communicates to the nurse that he does not want his family to see him. He indicates that he thinks the opening in his throat is disgusting. Which of the following nursing diagnoses would be most appropriate?
- A. Deficient knowledge about the care of a stoma.
- B. Disturbed personal identity related to change in appearance.
- C. Disturbed body image related to neck surgery.
- D. Hopelessness related to irreversible changes in body functioning.
Correct Answer: C
Rationale: Disturbed body image related to neck surgery addresses the client's negative feelings about the stoma's appearance. Deficient knowledge is less relevant here. Disturbed personal identity is broader. Hopelessness implies a deeper psychological state not fully supported by the description.
When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply.
- A. Checking the hemoglobin levels before administering subsequent doses.
- B. Shaking the vial thoroughly to mix the concentrated white, milky solution.
- C. Keeping the multidose vial refrigerated between scheduled twice-a-day doses.
- D. Administering the medication through the I.V. line without other medications.
- E. Adjusting the initial doses according to the client's changes in blood pressure.
- F. Educating the client to avoid driving and performing hazardous activity during the initial treatment.
Correct Answer: A,C,D,F
Rationale: For IV erythropoietin therapy, the nurse should check hemoglobin levels to monitor response and prevent overcorrection, keep multidose vials refrigerated to maintain stability, administer without mixing with other medications to avoid interactions, and educate about avoiding hazardous activities due to potential side effects like dizziness. Shaking the vial can denature the protein, and dose adjustments are typically based on hematologic response, not blood pressure.
A client is to be discharged with a prescription for lactulose (Cephulac). The nurse teaches the client and the client's spouse how to administer this medication. Which of the following statements would indicate that the client has understood the information?
- A. I'll take it with Maalox.'
- B. I'll mix it with apple juice.'
- C. I'll take it with a laxative.'
- D. I'll mix the crushed tablets in some gelatin.'
Correct Answer: B
Rationale: Mixing lactulose with apple juice (B) improves palatability. Maalox (A) is unrelated, additional laxatives (C) are unnecessary, and lactulose is a liquid, not a tablet (D).
Before undergoing a transsphenoidal hypophysectomy, the client asks the nurse how the surgeon will close the incision made in the dura. The nurse should respond based on the knowledge that:
- A. Dissolvable sutures are used to close the dura.
- B. Nasal packing provides pressure until normal wound healing occurs.
- C. A patch is made with a piece of fascia.
- D. A synthetic mesh is placed to facilitate healing.
Correct Answer: C
Rationale: A fascial patch is commonly used to repair the dura during transsphenoidal hypophysectomy to prevent CSF leaks.