A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care?

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Question 1 of 5

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care?

Correct Answer: A

Rationale: The correct intervention that should be part of the plan of care for a client at risk for impaired skin integrity due to external radiation is avoiding using a soap on the irradiated areas. Soap can be drying to the skin and may exacerbate skin reactions caused by radiation therapy. It is important to keep the skin in the radiation field clean, but avoiding soap will help prevent further irritation and damage to the skin. Instead, a gentle cleanser recommended by the healthcare provider should be used to clean the irradiated areas. Additionally, maintaining good hydration and moisturizing the skin as recommended by the healthcare team can also help minimize skin reactions.

Question 2 of 5

The nurse is teaching the parent of a child newly diagnosed with JRA. The nurse would evaluate the teaching as successful when the parent is able to say that the disorder is caused by:

Correct Answer: D

Rationale: The correct answer is D. Juvenile rheumatoid arthritis (JRA) is caused by the immune-stimulated inflammatory response in the joints. In JRA, the body's immune system attacks its own healthy joint tissues, leading to inflammation, pain, and damage to the joints. This chronic inflammation can cause joint stiffness, swelling, and in severe cases, joint deformities. It is not caused by the breakdown of osteoclasts in the joint space (A), the loss of cartilage in the joints (B), or the buildup of calcium crystals in joint spaces (C).

Question 3 of 5

Which of the following would the nurse teach the patient is the most common site for ear infections?

Correct Answer: B

Rationale: The most common site for ear infections is the middle ear. This area is prone to infections, especially in children, due to the Eustachian tube being shorter and more horizontal compared to adults. The middle ear is connected to the upper respiratory tract, allowing bacteria or viruses to easily travel and cause infections in this area. Symptoms of a middle ear infection include ear pain, fluid buildup, and possible hearing loss. Treatment may involve antibiotics and pain relief medications, and in some cases, surgical intervention may be necessary to drain the fluid.

Question 4 of 5

Which are clinical manifestations of the postterm newborn? (Select all that apply.)

Correct Answer: D

Rationale: Postterm newborns are infants born after 42 weeks of gestation. Some common clinical manifestations of postterm newborns include parchment-like, wrinkled skin due to prolonged exposure to amniotic fluid, and long fingernails as a result of intrauterine growth beyond the expected term. Excessive lanugo and absence of scalp hair are not typically seen in postterm newborns. Increased subcutaneous fat may be more common in infants born at term or post-term, but it is not a specific clinical manifestation of postterm newborns. Minimal vernix caseosa is also usually present in postterm newborns.

Question 5 of 5

These facts are true regarding the developmental stage of preschool children EXCEPT

Correct Answer: D

Rationale: Musturbation is not a recognized developmental milestone.

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