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While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?
- A. Wash the radiation site vigorously with soap and water to remove dead cells.
- B. Eat a diet high in protein and calories to optimize tissue repair.
- C. Apply coo! compresses to the radiation site to reduce edema,
- D. Drink warm fluids throughout the day to relieve discomfort in swallowing
Correct Answer: B
Rationale: Eating a diet high in protein and calories to optimize tissue repair would be the most appropriate instruction to suggest in this scenario. Dysphagia (difficulty swallowing) and skin texture changes can occur as side effects of radiation therapy for breast cancer. Protein is essential for tissue repair, while calories provide the necessary energy for the body to heal. By consuming a diet high in protein and calories, the client can support their body's healing process, minimize the risk of complications, and promote healing at the radiation site. It is important to note that maintaining proper nutrition is crucial during cancer treatment to support overall health and well-being.
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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: During the Schilling test, which is used to evaluate the absorption of vitamin B12 in the gastrointestinal system, the essential nursing intervention is to collect urine samples 24-48 hours after the client has received nonradioactive B12. The test involves administering both radioactive and nonradioactive forms of vitamin B12 to the client. The client's ability to absorb the vitamin B12 is assessed by measuring the amount of labeled B12 in the urine over the specified time period. This helps in diagnosing conditions such as pernicious anemia or malabsorption of vitamin B12. Blood samples are not typically collected for this test, and allowing fluid consumption is important to keep the client hydrated. The client does not need to lie down in a specific position for an extended period following nonradioactive B12 administration.
Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
- A. Imbalanced nutrition:Less than body requirements related to poor intake
- B. Disturbed sleep pattern related to external stimuli
- C. Impaired skin integrity related to pruritus
- D. Pain related to sickle cell crisis
Correct Answer: D
Rationale: Sickle cell crisis is characterized by intense pain due to the vaso-occlusive properties of sickled red blood cells leading to tissue ischemia. Therefore, pain is the primary nursing diagnosis that the nurse should expect to see in the plan of care for a client experiencing a sickle cell crisis. Managing and alleviating the pain is a priority in the care of these clients to improve quality of life and prevent complications. Other nursing diagnoses such as imbalanced nutrition, disturbed sleep pattern, and impaired skin integrity may not be directly related to the acute crisis and would not be the priority focus of care in this situation.
Why should the nurse wake up a client who is to undergo an EEG at midnight?
- A. Because excess sleep may make the client lazy and nervous for the EEG
- B. Because optimum sleep helps regulate the breathing patterns during the EEG
- C. Because it helps the client to fall asleep naturally during the EEG
- D. Because it reduces the chances of getting a headache when electrodes are fixed to the scalp of the client
Correct Answer: B
Rationale: The nurse should wake up a client who is to undergo an EEG at midnight to ensure that the client receives optimum sleep before the procedure. Optimum sleep helps regulate the client's breathing patterns during the EEG, resulting in more accurate readings. Adequate rest is essential for brain activity monitoring to be as normal as possible. Waking the client at midnight allows for enough time for the client to fall back asleep before the EEG is conducted, ensuring the best possible conditions for the procedure.
Reggie is a teenager suffering from osteomyelitis; the nurse would expect which of the following symptoms? Select all that apply.
- A. Fever
- B. Irritability
- C. Pallor
- D. Tenderness
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The bronchospasm and dyspnea are clinical manifestation of organophosphorus poisoning are caused by :
- A. muscarinic action
- B. nicotinic action
- C. CNS action
- D. all the above
Correct Answer: A
Rationale: The bronchospasm and dyspnea seen in organophosphorus poisoning are primarily caused by the muscarinic action of the toxic substance. Organophosphates inhibit acetylcholinesterase, leading to an excess of acetylcholine at the neuromuscular junctions. This results in overstimulation of muscarinic receptors, causing symptoms such as bronchoconstriction, increased secretions, and respiratory distress. Nicotinic actions primarily lead to muscle weakness and paralysis, while CNS actions can cause seizures and altered mental status. So, in the case of bronchospasm and dyspnea, the muscarinic action is the main contributing factor.