Weeks 4-7 Concept Recap

Jackson, who was recently diagnosed with melanoma, is about to begin immunotherapy. Which statement by the nurse best explains the purpose of this treatment?

• It replaces damaged immune cells with healthy donor cells.

• It kills all rapidly dividing cells to shrink the tumor.

• It helps your immune system specifically target and destroy cancer cells.

• It exposes cancer cells to external radiation to prevent them from multiplying.

Answer explanation

The correct statement explains that immunotherapy enhances the immune system's ability to specifically identify and eliminate cancer cells.

Priya is receiving chemotherapy and develops painful mouth sores. Which nursing action will best support her oral intake?

• Offer salted crackers between meals.

• Provide soft, bland foods and encourage frequent oral rinses with non-irritating solutions.

• Administer ondansetron 30 minutes before meals.

• Recommend rinsing the mouth with alcohol-based mouthwash after eating.

Answer explanation

Providing soft, bland foods and encouraging frequent oral rinses with non-irritating solutions helps minimize discomfort and promotes oral intake, making it the best choice for clients with painful mouth sores from chemotherapy.

Oliver, a client with Huntington’s disease, is under your care and is experiencing progressive chorea movements. Which intervention is most appropriate to support his nutritional needs?

• Restrict fluids to reduce aspiration risk.

• Provide a low-calorie, high-fiber diet to prevent weight gain.

• Offer frequent, high-calorie meals and snacks throughout the day.

• Teach the client about curative surgical treatment options.

Answer explanation

Offering frequent, high-calorie meals and snacks is essential for clients with Huntington's disease, as they often experience weight loss due to increased energy expenditure from chorea movements.

Emma, a nurse, is meeting with a client recently diagnosed with Huntington’s disease to discuss long-term care planning. Which nursing approach is most appropriate?

• Postpone sensitive conversations about future care until the client becomes symptomatic.

• Focus education on medication options that reverse disease progression.

• Initiate open discussions about end-of-life preferences while the client is cognitively able.

• Recommend fluid restrictions to reduce metabolic workload.

Answer explanation

Initiating open discussions about end-of-life preferences while the client is cognitively able allows for informed decision-making and respects the client's autonomy, which is crucial in progressive conditions like Huntington's disease.

Evelyn, a nurse, is caring for a client who recently began taking anti-seizure medication. During a follow-up evaluation, which finding would indicate to Evelyn that the medication is achieving its intended therapeutic effect?

• The client reports feeling more alert and focused.

• The client experiences improved muscle coordination during physical therapy.

• The client denies experiencing any adverse side effects.

• The client has not experienced a seizure in the past two weeks.

Answer explanation

The correct choice is that the client has not experienced a seizure in the past two weeks, indicating the anti-seizure medication is effectively controlling seizures, which is its primary therapeutic goal.

Avery, an elderly client, is admitted to the hospital with acute confusion due to a urinary tract infection. As a nurse, which environment would be most appropriate for Avery?

• A dim room at the end of the hallway to reduce stimulation

• A room near the nurses’ station with minimal noise and clutter

• A private room with frequent TV use to distract the client

• A shared room with another client who is oriented and verbal

Answer explanation

A room near the nurses’ station provides close monitoring and quick access to care, which is essential for an elderly client with acute confusion. Minimal noise and clutter help reduce anxiety and promote orientation.

Isla, a client admitted with delirium secondary to sepsis, is disoriented and attempting to get out of bed. Which nursing interventions are most appropriate? (Select all that apply.)

• Keep the bed in the lowest position with wheels locked

• Place a fall-risk bracelet on the client’s wrist

• Use bright overhead lights to help with orientation

• Administer prescribed IV fluids and antibiotics

Answer explanation

Keeping the bed low and locked prevents falls, while a fall-risk bracelet alerts staff. Administering IV fluids and antibiotics addresses the underlying sepsis, which is crucial for the client's recovery.

Maya, a nurse, is caring for a client who has developed delirium due to dehydration. What intervention is most important to support the client's recovery?

• Provide frequent reorientation using calendars and clocks

• Correct the underlying cause by administering IV fluids as prescribed

• Encourage independence by limiting assistance with ADLs

• Provide continuous mental stimulation with puzzles and games

Answer explanation

The most important intervention is to correct the underlying cause of delirium by administering IV fluids as prescribed. This addresses dehydration, which is crucial for recovery.

Noah, a nurse, is evaluating a client who has been receiving treatment for endometriosis. During a follow-up visit, the client shares some updates about her condition. Which client statement indicates the treatment has been successful?

• I've noticed I’m losing weight more easily now.

• My menstrual cycle has become more regular.

• The cramping, pain and pressure in my pelvis have decreased.

• My blood pressure has improved since starting treatment.

Answer explanation

The statement about decreased cramping, pain, and pressure indicates successful treatment for endometriosis, as these symptoms are primary concerns of the condition. The other statements do not directly reflect treatment efficacy.

Evelyn is brought to the emergency department with sudden weakness and difficulty speaking. The healthcare provider suspects an ischemic stroke due to her history of atrial fibrillation. Before administering alteplase, which diagnostic test must be completed?

• Electrocardiogram (ECG)

• Chest X-ray

• Head computed tomography (CT) scan

• Transthoracic echocardiogram (TTE)

Answer explanation

A head CT scan is essential to rule out hemorrhagic stroke before administering alteplase for an ischemic stroke. It ensures that there is no bleeding in the brain, which would contraindicate thrombolytic therapy.