Integumentary and Oncological Problems

The nurse caring for a client with iron deficiency anemia is preparing the client's plan of care. Which nursing diagnosis is the most appropriate for this client's care plan?

• A. Impaired gas exchange

• B. Ineffective airway clearance

• C. Deficient fluid volume

• D. Ineffective breathing pattern

Tags

NGSS.HS-LS1-3

NGSS.HS-LS1-7

The nurse is instructing a female client who is neutropenic. It would be appropriate for the nurse to recommend that she

• A. brush her teeth once a day or every other day.

• B. use pads instead of tampons during the menstrual cycle.

• C. create a ten feet distance between you and a visitor.

• D. wash your hands after cleaning up after pets.

Which of the following statements regarding pressure ulcers are true?

Select all that apply.

• A. In a stage II pressure ulcer, part of the dermis and epidermis are lost.

• B. In a stage I pressure ulcer, there is a loss of integrity of the epidermis only.

• C. In a stage III pressure ulcer, there is a deep tissue injury that can expose fat.

• D. In a stage IV pressure ulcer, the base of the wound is covered by eschar.

The nurse is caring for a client with epistaxis. The nurse should perform which appropriate action?

• A. Position the client upright and leaning forward while gently pinching their nose intermittently

• B. Position the client upright and leaning forward while gently pinching their nose continuously

• C. Ask the client to blow their nose and then put lateral pressure on the nose

• D. Instruct the client to hold their nose while bending forward at the waist

Select the skin disorder that is appropriately paired with an independent nursing intervention that can correct it or prevent it from getting worse.

• A. Erythema: The application of an antiseptic spray

• B. Excessive dryness: Using limited mild soap for bathing

• C. Abrasions: The application of an antimicrobial cream

• D. Hirsutism: Washing the area carefully and gently

The nurse is caring for a client with a breast tumor. The client reports trouble breathing, a puffy face/neck, nasal congestion, and a raspy voice. The nurse would suspect which of the following?

• A. Spinal cord compression

• B. Non-Hodgkin’s Lymphoma (NHL)

• C. Superior vena cava syndrome

• D. Shock

The nurse is caring for a client that is hypothermic and receiving warmed IV fluids. The nurse understands that rewarming must be done slowly due to which primary reason?

• A. To prevent burns in the patient.

• B. To prevent ventricular fibrillation and cardiovascular collapse.

• C. To prevent frostbite.

• D. To avoid muscle spasms.

The nurse is conducting a staff in-service on managing an acute burn. The nurse should reinforce the utilization of which formula to guide fluid resuscitation?

• A. 4 mL x kg x TBSA

• B. 30 mL/kg

• C. 0.5 mL/kg/hr

• D. 0.10 mL/kg/hr

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing ovarian cancer? Select all that apply.

Correct

• A. Nulliparity

• B. Advancing age

• C. Family history

• D. Herpes simplex virus (HSV)

• E. Early menarche

A client has acute bone pain related to metastases of cancer. The best way for a hospice nurse to assess the client's level of pain is:

• A. Check vital signs after giving pain medication.

• B. Note observations about the client's behavior.

• C. Evaluate verbal and non-verbal actions.

• D. Ask the client to rate their pain on a scale from 0-10.