All Nurses Care

Principles of Radiation Therapy

2011-06-22T11:57:00.000-07:00

TOPIC: PRINCIPLES OF RADIATION THERAPY(TIME, DISTANCE AND SHIELDING)

Radiation Therapy uses ionizing radiation to kill or limit the growth of cancer cells, may be internal or external. It not only injures the cell membrane but destroys or alters DNA so that the cells cannot reproduce. Like chemotherapy, effect cannot be limited to cancer cells only; all exposed cells, including normal ones, will be injured, causing side effects. Localized effects are related to area of body being treated; generalized effects may be related to cellular breakdown products.

Factors Controlling Exposure

A. Half-life: time required for half of radioactive atoms to decay

1. Each radioisotope has a different half-life.

2. At the end of the half-life, the danger from exposure decreases.

B. Time: the shorter the duration, the less the exposure

C. Distance: the greater the distance from the radiation source the less the exposure

D. Shielding: all radiation can be blocked; rubber gloves stop alpha and usually beta rays; thick lead or concrete stops gamma rays

E. These factors affect health care worker’s exposure as well as client’s.

1. Health care worker at greater risk from internal than external sources

a. Limit visitors to 30 mins. per day; visitors should be at least 6 feet from the source.

2. Film badge can measure the amount of exposure received

3. No pregnant nurses or visitors permitted near radiation source

HYPERTHYROIDISM

2011-06-11T11:59:00.000-07:00

DISEASE: HYPERTHYROIDISM- is a hyperthyroid state resulting from hypersecretion of thyroid hormones(T3 and T4), characterized by an increased rate of body metabolism, common cause is Grave’s disease also known as toxic diffuse goiter, clinical manifestations are referred to as thyrotoxicosis.

SIGNS & SYMPTOMS: Enlarged thyroid gland(goiter), palpitations, cardiac dysrhythmias, such as tachycardia or atrial fibrillation, protruding eyeballs(exophthalmos), hypertension, heat intolerance, diaphoresis, weight loss, diarrhea, smooth, soft skin and hair, pliable nails, nervousness and fine tremors of hands, personality changes, irritability and agitation, mood swings.

PATIENT TEACHINGS: Provide adequate rest. Provide cool and quiet environment. Obtain weight daily. Avoid administration of stimulants.

TREATMENTS: Administer sedatives as prescribed. Administer antithyroid medications(propylthiouracil(PTU) and methimazole(Tapazole)) that block thyroid synthesis, as prescribed. Administer iodine preparations that inhibit the release of thyroid hormone as prescribed. Administer propranolol(Inderal) for tachycardia as prescribed. Prepare the client for radioactive iodine therapy as prescribed to destroy thyroid cells. Prepare the client for thyroidectomy if prescribed.

DIET: Provide a high-calorie diet.

HYPOTHYROIDISM

2011-06-10T11:57:00.000-07:00

DISEASE: HYPOTHYROIDISM(myxedema) is a hypothyroid state resulting from a hyposecretion of the thyroid hormones T4 and T3, characterized by a decreased rate of body metabolism.

SIGNS & SYMPTOMS: Lethargy and fatigue, weakness, muscle aches, paresthesia, Intolerance to cold, weight gain, dry skin and hair, loss of body hair, bradycardia, anorexia, constipation, generalized puffiness and edema around the eyes and face, forgetfulness and loss of memory, menstrual disturbances, cardiac enlargement, tendency to develop congestive heart failure.

PATIENT TEACHINGS: Instruct the client about thyroid replacement therapy.

TREATMENTS: Monitor VS, including heart rate and rhythm. Administer thyroid replacement; levothyroxine sodium(Synthroid) is most commonly prescribed. Assess the client for constipation; provide roughage and fluids to prevent constipation. Provide a warm environment. Avoid sedatives and narcotics because of increased sensitivity to these medications.

DIETS AND DRUGS: Instruct client in low-calorie, low cholesterol, low saturated fat diet. Levothyroxine(Synthroid), Thyroglobulin(Proloid), Dessicated thyroid, Liothyronine(Cytomel) Thyroid hormone replacements are taken daily in the morning to prevent insomnia.

ADDISONIAN CRISIS

2011-06-09T16:41:00.000-07:00

DISEASE: ADDISONIAN CRISIS – a life threatening disorder caused by acute adrenal insufficiency. Crisis precipitated by stress, infection, trauma or surgery. It can cause hyponatremia, hyperkalemia, hypoglycemia and shock.

SIGNS & SYMPTOMS: Severe headache, severe abdominal, leg and lower back pain, Generalized weakness, Irritability and confusion, Severe hypotension, Shock.

PATIENT TEACHINGS: Maintain bed rest and provide a quiet environment.

TREATMENTS: Prepare to administer glucocorticoids intravenously as prescribed; hydrocortisone sodium succinate(Solu-Cortef) usually is prescribed initially. Following resolution of the crisis, administer glucocorticoid and mineralocorticoid orally as prescribed. Monitor vital signs, particularly BP. Monitor neurological status, noting irritability and confusion. Monitor I & O. Monitor lab values, particularly sodium, potassium and blood glucose. Administer IV fluids as prescribed to restore electrolyte balance. Protect the client from infection.

DIETS AND DRUGS: High protein, carbohydrate, & sodium intake. Dexamethasone, Hydrocortisone and Fludrocortisone.

ADDISON DISEASE

2011-06-08T16:39:00.000-07:00

ADDISON DISEASE – hyposecretion of adrenal cortex hormones (glucocorticoids & mineralocorticoids). Fatal if left untreated.

SIGNS & SYMPTOMS: Lethargy, fatigue & muscle weakness, GI disturbances, wt. loss, menstrual changes in women, impotence in men, hypoglycemia, hyperkalemia, postural hypotension, dehydration, emotional disturbances

PATIENT TEACHINGS: Avoid individuals with infection, strenuous exercise & stressful situations. Need for lifelong glucocorticoid therapy. Avoid OTC meds. Wear medic-alert bracelet.

TREATMENTS: Monitor VS, BP, wt. and I & O. Monitor blood glucose, and potassium. Administer glucocorticoid or mineralocorticoid medications as prescribed.

DIETS AND DRUGS: High protein, carbohydrate, & sodium intake. Dexamethasone, Hydrocortisone and Fludrocortisone.

CUSHINGS DISEASE

2011-06-06T15:00:00.000-07:00

DISEASE: CUSHINGS – is a condition of hypersecretion of glucocorticoids from adrenal cortex. Can be caused by increased pituitary secretion of ACTH, pituitary adenoma, or adrenal adenoma.

SIGNS & SYMPTOMS: Truncal obesity with thin extremities, moonface, buffalo hump, supraclavicular fat pads, generalized muscle wasting & weakness, fragile skin that bruise, reddish-purple striae on abdomen & upper thigh, hirsutism, hypertension, elevated blood glucose,sodium and WBC, decreased calcium and potassium

PATIENT TEACHINGS: Monitor VS, BP, I&O, weight, lab.values particularly blood glucose,WBC,Na,K,Ca. Provide good skin care.

TREATMENTS: Prepare client for hypophysectomy or radiation if condition is caused by pituitary tumor. Prepare client for adrenalectomy if condition is caused by adrenal tumor or hyperplasia.

DIETS AND DRUGS: Medications to control excessive production of cortisol include ketoconazole (Nizoral), mitotane (Lysodren) and metyrapone (Metopirone).

In some cases, the tumor or its treatment will cause other hormones produced by the pituitary or adrenal gland to become deficient and your doctor will recommend hormone replacement medications.

Provide diet low in calories & sodium and high in protein, potassium, calcium and vitamin D.

NCLEX Q & A's Part 2

2011-02-12T16:33:00.000-08:00

1. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

A. Place the client in a sitting position with the head hyperextended

B. Pack the nares tightly with gauze to apply pressure to the source of bleeding

C. Pinch the soft lower part of the nose for a minimum of 5 minutes

D. Apply ice packs to the forehead and back of the neck

2. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:

A. Blood pressure

B. Temperature

C. Output

D. Specific gravity

3. A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

A. Glucometer readings as ordered

B. Intake/output measurements

C. Sodium and potassium levels monitored

D. Daily weights

4. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?

A. Obtain a crash cart

B. Check the calcium level

C. Assess the dressing for drainage

D. Assess the blood pressure for hypertension

5. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

A. Impaired physical mobility related to decreased endurance

B. Hypothermia r/t decreased metabolic rate

C. Disturbed thought processes r/t interstitial edema

D. Decreased cardiac output r/t bradycardia

6. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?

A. Report muscle weakness to the physician.

B. Allow six months for the drug to take effect.

C. Take the medication with fruit juice.

D. Ask the doctor to perform a complete blood count before starting the medication.

7. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

A. Utilize an infusion pump

B. Check the blood glucose level

C. Place the client in Trendelenburg position

D. Cover the solution with foil

8. The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

A. Blood pressure of 126/80

B. Blood glucose of 110mg/dL

C. Heart rate of 60bpm

D. Respiratory rate of 30 per minute

9. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

A. Replenish his supply every 3 months

B. Take one every 15 minutes if pain occurs

C. Leave the medication in the brown bottle

D. Crush the medication and take with water

10. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

A. Macaroni and cheese

B. Shrimp with rice

C. Turkey breast

D. Spaghetti

11. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

A. Feet

B. Neck

C. Hands

D. Sacrum

12. The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:

A. Phlebostatic axis

B. PMI

C. Erb's point

D. Tail of Spence

13. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

A. Question the order

B. Administer the medications

C. Administer separately

D. Contact the pharmacy

14. The best method of evaluating the amount of peripheral edema is:

A. Weighing the client daily

B. Measuring the extremity

C. Measuring the intake and output

D. Checking for pitting

15. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

A. Overnight stays by family members is against hospital policy.

B. There is no need for him to stay because staffing is adequate.

C. His wife will rest much better knowing that he is at home.

D. Visitation is limited to 30 minutes when the implant is in place.

16. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

A. Roast beef sandwich, potato chips, pickle spear, iced tea

B. Split pea soup, mashed potatoes, pudding, milk

C. Tomato soup, cheese toast, Jello, coffee

D. Hamburger, baked beans, fruit cup, iced tea

17. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

A. "I will make sure I eat breakfast within 10 minutes of taking my insulin."

B. "I will need to carry candy or some form of sugar with me all the time."

C. "I will eat a snack around three o'clock each afternoon."

D. "I can save my dessert from supper for a bedtime snack."

18. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:

A. New parents need time to learn how to hold the baby.

B. The umbilical cord needs time to separate.

C. Newborn skin is easily traumatized by washing.

D. The chance of chilling the baby outweighs the benefits of bathing.

19. A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

A. Treat iron-deficiency anemia caused by chemotherapeutic agents

B. Create a synergistic effect that shortens treatment time

C. Increase the number of circulating neutrophils

D. Reverse drug toxicity and prevent tissue damage

20. A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

A. Hib titer

B. Mumps vaccine

C. Hepatitis B vaccine

D. MMR

21. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

A. 30 minutes before meals

B. With each meal

C. In a single dose at bedtime

D. 30 minutes after meals

22. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

A. Call security for assistance and prepare to sedate the client.

B. Tell the client to calm down and ask him if he would like to play cards.

C. Tell the client that if he continues his behavior he will be punished.

D. Leave the client alone until he calms down.

23. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

A. Check the client for bladder distention

B. Assess the blood pressure for hypotension

C. Determine whether an oxytocic drug was given

D. Check for the expulsion of small clots

24. A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:

A. Pneumonia

B. Reaction to antiviral medication

C. Tuberculosis

D. Superinfection due to low CD4 count

25. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?

A. Diabetes

B. Prinzmetal's angina

C. Cancer

D. Cluster headaches

26. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:

A. Pain on flexion of the hip and knee

B. Nuchal rigidity on flexion of the neck

C. Pain when the head is turned to the left side

D. Dizziness when changing positions

27. The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

A. Agnosia

B. Apraxia

C. Anomia

D. Aphasia

28. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

A. Chronic fatigue syndrome

B. Normal aging

C. Sundowning

D. Delusions

29. The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

A. "You know you had breakfast 30 minutes ago."

B. "I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse."

C. "I'll get you some juice and toast. Would you like something else?"

D. "You will have to wait a while; lunch will be here in a little while."

30. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?

A. Urinary incontinence

B. Headaches

C. Confusion

D. Nausea

Answers and Rationales:

1. Answer C is correct. The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.

2. Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.

3. Answer A is correct. IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.

4. Answer B is correct. The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.

5. Answer D is correct. The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.

6. Answer A is correct. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyositis. The medication takes effect within 1 month of beginning therapy, so answer B is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.

7. Answer B is correct. Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not a Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.

8. Answer C is correct. A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers A, B, and D are incorrect.

9. Answer C is correct. Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer D.

10. Answer C is correct. Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client; thus, answers A, B, and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.

11. Answer B is correct. The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.

12. Answer A is correct. The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously, making answer C incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.

13. Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.

14. Answer B is correct. The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.

15. Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.

16. Answer B is correct. The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers A, C, and D would require more chewing and, thus, are incorrect.

17. Answer A is correct. Novalog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect because there is no need to save the dessert until bedtime.

18. Answer B is correct. The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers A, C, and D might be important, they are not the primary answer to the question.

19. Answer D is correct. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.

20. Answer A is correct. The Hemophilus influenza vaccine is given at 4 months with the polio vaccine. Answers B, C, and D are incorrect because these vaccines are given later in life.

21. Answer B is correct. Proton pump inhibitors such as Nexium and Protonix should be taken with meals, for optimal effect. Histamine-blocking agents such as Zantac should be taken 30 minutes before meals, so answer A is incorrect. Tagamet can be taken in a single dose at bedtime, making answer C incorrect. Answer D does not treat the problem adequately and, therefore, is incorrect.

22. Answer A is correct. If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Answer B is incorrect because simply telling the client to calm down will not work. Answer C is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Answer D is incorrect because if the client is left alone he might harm himself.

23. Answer A is correct. If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The answers in B, C, and D are actions that relate to postpartal hemorrhage.

24. Answer C is correct. A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in A had said pneumocystis pneumonia, answer A would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Answers B and D are not directly related to the stem.

25. Answer B is correct. If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect.

26. Answer A is correct. Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign.

27. Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers A, C, and D are incorrect.

28. Answer C is correct. Increased confusion at night is known as "sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore, answer D is incorrect.

29. Answer C is correct. The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion.

30. Answer D is correct. Nausea and gastrointestinal upset are very common in clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, answers A, B, and C are incorrect.

NCLEX Q & A's

2011-02-11T16:11:00.000-08:00

1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?

A. Body temperature of 99°F or less

B. Toes moved in active range of motion

C. Sensation reported when soles of feet are touched

D. Capillary refill of < 3 seconds

2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

A. Side-lying with knees flexed

B. Knee-chest

C. High Fowler's with knees flexed

D. Semi-Fowler's with legs extended on the bed

3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

A. Taking hourly blood pressures with mechanical cuff

B. Encouraging fluid intake of at least 200mL per hour

C. Position in high Fowler's with knee gatch raised

D. Administering Tylenol as ordered

4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

A. Peaches

B. Cottage cheese

C. Popsicle

D. Lima beans

5. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.

A. Adjust the room temperature

B. Give a bolus of IV fluids

C. Start O₂

D. Administer meperidine (Demerol) 75mg IV push

6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

A. Roast beef, gelatin salad, green beans, and peach pie

B. Chicken salad sandwich, coleslaw, French fries, ice cream

C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

D. Pork chop, creamed potatoes, corn, and coconut cake

7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

A. A family vacation in the Rocky Mountains

B. Chaperoning the local boys club on a snow-skiing trip

C. Traveling by airplane for business trips

D. A bus trip to the Museum of Natural History

8. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?

A. Palpate the spleen

B. Take the blood pressure

C. Examine the feet for petechiae

D. Examine the tongue

9. An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?

A. Conjunctiva of the eye

B. Soles of the feet

C. Roof of the mouth

D. Shins

10. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

A. BP 146/88

B. Respirations 28 shallow

C. Weight gain of 10 pounds in 6 months

D. Pink complexion

11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

A. "I will drink 500mL of fluid or less each day."

B. "I will wear support hose when I am up."

C. "I will use an electric razor for shaving."

D. "I will eat foods low in iron."

12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?

A. The client collects stamps as a hobby.

B. The client recently lost his job as a postal worker.

C. The client had radiation for treatment of Hodgkin's disease as a teenager.

D. The client's brother had leukemia as a child.

13. An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?

A. The abdomen

B. The thorax

C. The earlobes

D. The soles of the feet

14. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

A. "Have you noticed a change in sleeping habits recently?"

B. "Have you had a respiratory infection in the last 6 months?"

C. "Have you lost weight recently?"

D. "Have you noticed changes in your alertness?"

15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

A. Oral mucous membrane, altered related to chemotherapy

B. Risk for injury related to thrombocytopenia

C. Fatigue related to the disease process

D. Interrupted family processes related to life-threatening illness of a family member

16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

A. Sexual dysfunction related to radiation therapy

B. Anticipatory grieving related to terminal illness

C. Tissue integrity related to prolonged bed rest

D. Fatigue related to chemotherapy

17. A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:

A. Platelet count

B. White blood cell count

C. Potassium levels

D. Partial prothrombin time (PTT)

18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about:

A. Bleeding precautions

B. Prevention of falls

C. Oxygen therapy

D. Conservation of energy

19. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?

A. Place the client in Trendelenburg position for postural drainage

B. Encourage coughing and deep breathing every 2 hours

C. Elevate the head of the bed 30°

D. Encourage the Valsalva maneuver for bowel movements

20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

A. Measure the urinary output

B. Check the vital signs

C. Encourage increased fluid intake

D. Weigh the client

Answers and Rationales

1. Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.

2. Answer D is correct. Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect.

3. Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.

4. Answer C is correct. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.

5. Answer C is correct. The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.

6. Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect.

7. Answer D is correct. Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect.

8. Answer D is correct. The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur, making answers A, B, and C incorrect.

9. Answer C is correct. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect.

10. Answer B is correct. When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.

11. Answer A is correct. The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.

12. Answer C is correct. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.

13. Answer D is correct. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin might be too dark to make an assessment.

14. Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

15. Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.

16. Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.

17. Answer A is correct. Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect.

18. Answer A is correct. The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.

19. Answer C is correct. Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.

20. Answer B is correct. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.

Ephedra

2011-02-10T19:54:00.000-08:00

Dietary supplements that contain ephedra have been banned in the United States since April 2004.

Use for asthma and bronchitis.

Contains ephedrine.

Black cohosh

2011-02-09T19:49:00.000-08:00

Has a history of use for rheumatism (arthritis and muscle pain).

Has been used more recently to treat hot flashes, night sweats, vaginal dryness, and other symptoms that can occur during menopause.

Black cohosh has also been used for menstrual irregularities and premenstrual syndrome, and to induce labor.

Evening Primrose

2011-02-08T19:33:00.000-08:00

Help prevent hardening of the arteries, heart disease.

PMS

High blood pressure. Aids in lowering cholesterol levels.

Research also demonstrates that primrose oil helps relieve pain and inflammation