The following are warning signs of cancer. Which one is not?

Correct Answer: B

Rationale: Weight gain is not typically considered a warning sign of cancer. In fact, unexplained weight loss is more commonly associated with certain types of cancer. The other options all relate to symptoms that could potentially be warning signs of cancer and are worth discussing with a healthcare professional for further evaluation.

Correct Answer: C

Rationale: The presence of fluid in both lung bases, as indicated by the chest x-ray examination, suggests the possibility of pulmonary congestion or fluid accumulation in the lungs. Bilateral crackles, also known as rales, are a common clinical finding associated with pulmonary edema. Crackles are discontinuous, brief, popping sounds heard on auscultation of the lungs. These adventitious breath sounds occur when air passes through fluid in the small airways or alveoli. Therefore, the presence of bilateral crackles during the nurse's assessment would most reflect the x-ray examination findings of fluid in both lung bases. Fatigue, peripheral edema, and jugular vein distention may also be present in conditions involving fluid overload, such as heart failure, but bilateral crackles specifically point to the presence of fluid in the lungs.

Correct Answer: C

Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.

Correct Answer: C

Rationale: The nurse instructs the client to avoid Valsalva maneuvers because the client may suffer from a myocardial infarction. The Valsalva maneuver involves forcefully trying to exhale against a closed airway, which can increase intra-thoracic pressure and subsequently increase blood pressure. This can lead to an increased workload on the heart, potentially causing myocardial ischemia or infarction in individuals with underlying heart conditions. Therefore, it is important to avoid Valsalva maneuvers, especially in clients at risk for cardiovascular issues.

Correct Answer: C

Rationale: Option C, which is to toilet the patient according to his pre-illness schedule, whether or not he feels the urge, is the best intervention by the nurse to help reduce episodes of bowel incontinence in this patient with subarachnoid hemorrhage. This strategy can help establish a routine and promote regular bowel movements, which may reduce the likelihood of bowel incontinence episodes. Asking the patient frequently if he has to have a bowel movement (Option A) may not be effective, as the patient may not always be able to accurately communicate their needs due to the underlying condition. Placing incontinence pads on the patient's bed and chair (Option B) may manage the consequences of incontinence but does not address the root cause. While taking care not to embarrass the patient when incontinent episodes occur (Option D) is important for maintaining the patient's dignity, it does not directly address the issue of reducing bowel incontinence episodes.