The nurse understands that the diagnosis of oral cancer is confirmed with:
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Solution
Answer A is correct. The best diagnostic tool for cancer is the biopsy. Other assessment includes checking the lymph nodes. Answers B, C, and D will not confirm a diagnosis of oral cancer.
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
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Solution
Answer C is correct. The new diabetic has a knowledge deficit. Answers A, B, and D are not supported within the stem and so are incorrect.
The nurse is asked by the nurse aide, “Are peptic ulcers really caused by stress?” The nurse would be correct in replying with which of the following:
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Solution
Answer D is correct. H. pylori bacteria and stress are directly related to peptic ulcers. Answers A and B are incorrect because peptic ulcers are not caused by overeating or always caused by continued stress. Answer C is incorrect because peptic ulcers are related to but not directly caused by stress.
The nurse is assisting in the assessment of the patient admitted with abdominal pain. Why should the nurse ask about medications that the client is taking?
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Solution
Answer B is correct. Many medications can irritate the stomach and contribute to abdominal pain. For answer A, the primary reason for asking about medications is not to identify interactions between medication. Although this might provide an opportunity for teaching, this is not the best time to teach. Therefore, answers C and D are incorrect.
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
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Solution
Answer A is correct. The nurse should inspect first, then auscultate, and finally palpate. If the nurse palpates first the assessment might be unreliable. Therefore, answers B, C, and D are incorrect.
The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?
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Solution
Answer A is correct. Contacting organ retrieval to talk to the family member is the best choice because a trained specialist has the knowledge to assist the wife with making the decision to donate or not to donate the client’s organs. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect; answer C might be done, but there might not be time; and answer D is not good nursing etiquette and, therefore, is incorrect.
The client with brain cancer refuses to care for herself. Which action by the nurse would be best?
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Solution
Answer C is correct. The nurse should explore the cause for the lack of motivation. The client might be anemic and lack energy, might be in pain, or might be depressed. Alternating staff, as stated in answer A, will prevent a bond from being formed with the nurse. Answer B is not enough, and answer D is not necessary.
The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which action should the charge nurse take?
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Solution
Answer D is correct. The nurse who has had the chickenpox has immunity to the illness. Answer A is incorrect because more information is needed to determine whether a change in assignment is necessary. Answer B is incorrect because there could be a risk to the immune-suppressed client. Answer C is incorrect because the client who is immune-suppressed could still be at risk from the nurse’s exposure to the chickenpox, even if scabs are present.
The nurse is caring for the client with a mastectomy. Which action would be contraindicated?
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Solution
Answer A is correct. The nurse should not take the blood pressure on the affected side. Also, venopunctures and IVs should not be used in the affected area. Answers B, C, and D are all indicated for caring for the client. The arm should be elevated to decrease edema. It is best to position the client on the unaffected side and perform a dextrostix on the unaffected side.
The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication?
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Solution
Answer B is correct. Gentamycin is a drug from the aminoglycocide classification. These drugs are toxic to the auditory nerve and the kidneys. The hematocrit is not of significant consideration in this client; therefore, answer A is incorrect. Answer C is incorrect because we would expect the white blood cell count to be elevated in this client because gentamycin is an antibiotic. Answer D is incorrect because the erythrocyte count is also particularly significant to check.