The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?

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Question 1 of 9

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?

Correct Answer: C

Rationale: The correct answer is C: Interdependent. In this scenario, the nurse performed an intervention for a collaborative problem, which involves working together with other healthcare professionals to address the issue. Interdependent interventions require collaboration and communication among healthcare team members to achieve the best outcomes for the patient. Choice A (Dependent Nursing) refers to interventions that require an order from a healthcare provider. Choice B (Independent) involves nursing actions that the nurse can initiate without the need for a healthcare provider's order. Choice D (Physician-initiated) specifically denotes interventions initiated by a physician without direct involvement from the nurse. In this case, the nurse's intervention for a collaborative problem aligns with the definition of interdependent intervention, making it the correct choice.

Question 2 of 9

Which of the ff are the most significant symptoms of Hodgkin’s disease category B? Choose all that apply

Correct Answer: C

Rationale: The correct answer is C: Night sweats. In Hodgkin's disease category B, the presence of night sweats signifies more advanced disease and higher tumor burden. Night sweats are a B-symptom, along with fever and weight loss, indicating systemic symptoms. Anemia (choice B) and thrombocytopenia (choice D) are not specific to Hodgkin's disease category B and can be present in various other conditions. Fever (choice A) is not exclusive to Hodgkin's disease category B and can occur in many infections and inflammatory conditions. Night sweats are specifically associated with Hodgkin's disease and are a key indicator of disease severity in this context.

Question 3 of 9

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?

Correct Answer: C

Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own. Incorrect Answers: A: Purplish stools - This is not a common side effect of lymphangiography. B: Redness of the upper part of the feet - Redness is not typically associated with this procedure. D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.

Question 4 of 9

Which of these signs suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Correct Answer: C

Rationale: The correct answer is C: Neck vein distention. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia, causing fluid overload. This can manifest as neck vein distention due to increased venous pressure. Tetanic contractions (A) and weight loss (B) are not typical complications of SIADH; tetany is more associated with hypocalcemia and weight loss is not a common manifestation. Polyuria (D) is actually the opposite of what is seen in SIADH, which is characterized by water retention and concentrated urine.

Question 5 of 9

Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?

Correct Answer: D

Rationale: The correct answer is D because it offers the patient autonomy by providing a choice between brushing their teeth independently or having assistance. This empowers the patient to make decisions regarding their personal hygiene, promoting independence and self-esteem. Choice A does not offer a choice or empower the patient. Choice B focuses solely on the location of the toothbrush and does not address the patient's needs. Choice C does not provide the patient with a sense of control over their hygiene routine. By contrast, choice D acknowledges the patient's needs, offers a choice, and encourages independence.

Question 6 of 9

Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain

Correct Answer: C

Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.

Question 7 of 9

While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?

Correct Answer: B

Rationale: The correct answer is B: Eat a diet high in protein and calories to optimize tissue repair. Rationale: 1. Protein is essential for tissue repair and healing, which can help counteract the effects of radiation therapy on the skin and swallowing function. 2. Calories are necessary for energy to support the body's healing processes during radiation therapy. 3. A diet high in protein and calories can help maintain overall nutritional status and promote recovery. Incorrect Choices: A: Washing the radiation site vigorously can further irritate the skin, leading to more complications. C: Cool compresses may not be suitable for radiation-induced skin reactions and may not address the underlying issue of dysphagia. D: Drinking warm fluids may not directly address the need for optimal tissue repair and healing.

Question 8 of 9

Approximately how much fluid is lost in acute weight loss of .5kg?

Correct Answer: C

Rationale: The correct answer is C: 500 ml. When someone loses 0.5 kg of weight, it is estimated that about 500 ml of fluid has been lost, as 1 kg of body weight is roughly equivalent to 1 liter of fluid. This fluid loss is due to water loss through sweating, breathing, and urine. Choice A (50 ml) is too small of an amount for a significant weight loss. Choice B (750 ml) is too high and would correspond to a larger weight loss. Choice D (75 ml) is also too small to account for a 0.5 kg weight loss.

Question 9 of 9

A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?

Correct Answer: D

Rationale: The correct answer is D because crying whenever diabetes is mentioned indicates emotional distress, a key component of ineffective coping. This response suggests the client is overwhelmed by the diagnosis, affecting their ability to cope effectively. In contrast, choices A, B, and C focus more on physical aspects and management of diabetes, not coping mechanisms. Weight gain could be related to poor diet or medication side effects, skipping insulin doses might indicate non-adherence, and failure to monitor blood glucose could be due to lack of knowledge or resources. Overall, D is the best choice as it directly relates to the client's emotional response to the diagnosis.

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