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Which screening test for colorectal cancer should the nurse recommend?
- A. Carcinoembryonic antigen (CEA) test
- B. Annual digital examination after age 50
- C. Barium enema after age 50
- D. Proctosigmoidoscopy after age 50
Correct Answer: D
Rationale: The correct screening test for colorectal cancer is D: Proctosigmoidoscopy after age 50. This test allows direct visualization of the lower colon and rectum, aiding in the detection of polyps or tumors. It is recommended for individuals over 50 years old to screen for colorectal cancer. A: CEA test is not a primary screening tool but rather used for monitoring cancer progression. B: Annual digital examination is not sufficient for colorectal cancer screening. C: Barium enema is less effective compared to colonoscopy for detecting abnormalities in the colon.
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or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. “Client verbalizes feelings of anxiety.”
- B. “Client doesn’t guess at prognosis.”
- C. “Client uses any effective method to reduce tension.”
- D. “Client stops seeking information.”
Correct Answer: A
Rationale: The correct answer is A because it reflects a measurable and client-centered outcome. Verbalizing feelings of anxiety indicates the client is acknowledging and addressing their emotions, which is essential in managing anxiety. Choice B is incorrect as it focuses on avoidance rather than expression of emotions. Choice C is incorrect as it doesn't specify the use of appropriate coping mechanisms. Choice D is incorrect as it suggests avoidance of seeking information, which may hinder the client's understanding and coping with the diagnosis.
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
- A. orthopnea
- B. fever
- C. weight loss
- D. calf pain A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET O
Correct Answer: A
Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat.
Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe.
Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection.
Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF.
Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF.
Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
- A. Active exercise
- B. Use of tilt board
- C. Deep massage
- D. Proper positioning
Correct Answer: D
Rationale: Step 1: Proper positioning helps maintain alignment and prevent deformities in muscles and joints.
Step 2: It reduces the risk of contractures by ensuring that Mr. Gabatan's lower extremities are in optimal positions.
Step 3: This promotes circulation and reduces pressure on bony prominences.
Step 4: Active exercise may exacerbate spasticity, tilt board may not address positioning adequately, and deep massage may not prevent contractures effectively.
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. In the first phase of the nursing process (assessment), the nurse collects data to form a comprehensive database about the patient's health status. This step is crucial as it provides the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining whether outcomes have been achieved (D) is in the fourth phase (evaluation). Completing a comprehensive database in the first phase ensures a thorough understanding of the patient's needs before proceeding to the next steps in the nursing process.
Which of the ff nursing interventions is essential for a client during the Schilling test?
- A. Collecting urine 24-48 hrs after the client has received nonradioactive B12
- B. Collecting blood samples of 50 ml for 24-48 hrs after the client has received the nonradioactive B12
- C. Not allowing any oral fluid consumption for 24-48 hrs after the client has received nonradioactive B12
- D. Making the client lie down in the supine position for 24-48 hrs after the client has received nonradioactive B12 CARING FOR CLIENTS WITH DISORDERS OF THE HEMATOPOIETIC SYSTEM
Correct Answer: A
Rationale: The correct answer is A because collecting urine 24-48 hrs after the client has received nonradioactive B12 is essential for the Schilling test to evaluate vitamin B12 absorption. Urine is collected to measure the excretion of radioactive B12, which helps in diagnosing pernicious anemia or malabsorption issues.
Incorrect choices:
B: Collecting blood samples is not necessary for the Schilling test as it primarily involves urine collection.
C: Allowing oral fluid consumption is important to prevent dehydration and is not contraindicated after receiving nonradioactive B12.
D: Making the client lie down in the supine position is unnecessary for the Schilling test and may not affect the test results.