A patient with a new diagnosis of lymphoma is experiencing fatigue. Which of the ff. is the best way to assess her fatigue?

Correct Answer: B

Rationale: The best way to assess a patient's fatigue is to have her rate her fatigue on a scale of 0 to 10. Fatigue is primarily a subjective symptom, and patients are the best source of information regarding their own levels of fatigue. Using a standardized scale allows for a more quantitative assessment of the severity of the fatigue experienced by the patient. This can also help in monitoring changes in fatigue over time and evaluating the effectiveness of interventions aimed at managing fatigue. While observing the patient's activity level (choice A) can provide some information, it may not always accurately reflect the subjective experience of fatigue. Monitoring for changes in vital signs (choice C) and assessing hemoglobin and hematocrit values (choice D) can be important in evaluating overall health status and potential causes of fatigue, but they do not directly assess the patient's subjective experience of fatigue.

Correct Answer: A

Rationale: In caring for a client with lymphangitis, it is crucial for the nurse to be vigilant for any signs of worsening condition. The correct answer is option A, which states that the affected area appears to enlarge. This is the most critical symptom indicating progression of the infection along the lymphatic vessels. Enlargement suggests increasing inflammation and potential complications, necessitating immediate physician notification for further evaluation and intervention. Options B, C, and D are incorrect. Red streaks extending up the arm or leg (option B) are actually a classic sign of lymphangitis and should not trigger physician notification unless they worsen significantly or are accompanied by other concerning symptoms. Additional lymph nodes becoming involved (option C) is a common response to infection and does not necessarily warrant immediate physician notification unless they are unusually enlarged or painful. Enlargement of the liver and spleen (option D) is not directly related to lymphangitis and would typically be indicative of a different condition. In an educational context, understanding the progression of lymphangitis and recognizing concerning signs is crucial for nurses caring for pediatric patients. This knowledge helps in timely interventions and preventing complications. Nurses need to prioritize assessments and interventions based on the most critical indicators of worsening condition to provide optimal care for their patients.

Correct Answer: B

Rationale: Rationale: The correct answer is option B) "Keep the stoma dry." In caring for a neck stoma post-laryngectomy, it is crucial to keep the stoma dry to prevent irritation and infection. Moisture can lead to breakdown of the skin around the stoma, increasing the risk of infection. Keeping the stoma dry also helps in maintaining the integrity of the stoma site and promotes healing. Option A) "Keep the stoma uncovered" is incorrect because covering the stoma helps protect it from environmental contaminants and can prevent accidental trauma. Option C) "Have a family member perform stoma care initially until you get used to the procedure" is incorrect as it is important for the client to learn how to care for the stoma themselves to promote independence and self-care. Option D) "Keep the stoma moist" is incorrect as moisture can lead to skin breakdown and increase the risk of infection, as mentioned earlier. Educationally, it is essential for nurses to provide accurate and detailed instructions to clients undergoing laryngectomy to ensure proper stoma care, prevent complications, and promote optimal healing and adaptation to the changes post-surgery. Empowering the client with the knowledge and skills to care for their stoma is crucial for their long-term well-being and quality of life.

Correct Answer: A

Rationale: It is appropriate to inform the male client that testicular cancer is a highly curable type of cancer. Testicular cancer has a high cure rate, especially when detected early through self-examinations. By emphasizing the curability of this cancer, the nurse can empower the client to perform regular self-exams and seek prompt medical attention if any abnormalities are detected. This information can help alleviate fears and encourage proactive health behaviors.

Correct Answer: A

Rationale: The liver is one of the most common sites for metastasis of cancer cells. This is because the liver receives a high volume of blood flow, making it a common site for cancer cells to spread through the bloodstream. Additionally, the liver's function in filtering toxins and foreign substances from the blood makes it a favorable environment for cancer cells to establish secondary tumors. Monitoring the liver for metastasis is crucial in cancer diagnosis and management.