\What should the nurse teach an older client with TIA?

Correct Answer: C

Rationale: The correct answer is C: To comply with the medication regimen. Teaching the older client with TIA to comply with medication regimen is crucial in preventing further TIAs or strokes. Medications like antiplatelets or anticoagulants are often prescribed to manage TIA. This education empowers the client to actively participate in their own health management. Incorrect choices: A: Not to worry about the symptoms that are part of the normal aging process - This is incorrect as TIA symptoms are not considered a normal part of aging and should not be ignored. B: To admit oneself to a rehabilitation center or a nursing home for rehabilitation - This is incorrect as it is not the primary intervention for managing TIA. D: To observe any changes in the nails and skin - This is incorrect as it is not directly related to managing TIA.

Correct Answer: A

Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.

Correct Answer: B

Rationale: The correct answer is B: radiation therapy. Radiation therapy uses high-energy radiation to target and destroy cancer cells while minimizing damage to surrounding healthy tissues. It is a localized treatment that is effective in shrinking tumors and preventing cancer cell growth. Surgery (A) involves physically removing the tumor and surrounding tissues, while chemotherapy (C) uses drugs to kill cancer cells throughout the body. Palliative treatment (D) focuses on symptom management and improving quality of life in advanced stages of cancer. In this case, the focus is on a form of cancer therapy involving high-energy electromagnetic radiation, making radiation therapy the most appropriate choice.

Correct Answer: A

Rationale: The correct answer is A. 1. Change in level of consciousness is crucial in assessing neurological status. 2. Tachypnea indicates possible respiratory distress or oxygenation issues. 3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion. 4. Petechiae can be a sign of bleeding disorders or sepsis. Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms. Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E. Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.

Correct Answer: B

Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5 FU [Fluoroplex]). Fluorouracil is commonly used in chemotherapy for liver cancer to inhibit cancer cell growth. It is a pyrimidine analog that interferes with DNA synthesis. Fluoxymesterone (A) is an androgen used in hormone replacement therapy, not in liver cancer treatment. Tamoxifen (C) is an antiestrogen used in breast cancer treatment, not liver cancer. Megestrol (D) is a progestin used in hormone therapy for breast cancer and endometrial cancer, not liver cancer. Therefore, the correct choice is B as it directly targets cancer cell growth in liver cancer treatment.

Correct Answer: B

Rationale: The correct answer is B: Efferent. Efferent neurons transmit signals from the central nervous system to muscles and glands, controlling movement and secretion. Afferent neurons carry signals from sensory receptors to the central nervous system, not towards muscles or glands. "Affective" relates to emotions, not neural function. "Effective" does not describe the direction of signal transmission in the nervous system. Therefore, B is the correct choice.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather data from the patient's body, such as vital signs, appearance, and overall health status. It provides essential information to establish a patient's database, including baseline values and potential health issues. Reviewing current literature (A) helps in decision-making but does not directly establish a patient's database. Checking orders for tests (B) and ordering medications (D) are part of the treatment process and do not focus on gathering initial patient data.

Correct Answer: C

Rationale: The correct answer is C: He walked home in a cold rain. Walking in cold rain can lead to vasoconstriction, which impairs blood flow, increasing the likelihood of a sickle cell crisis in individuals with sickle cell disease. This can cause red blood cells to sickle and block blood vessels, leading to pain and tissue damage. Choices A, B, and D do not directly affect the physiology of sickle cell disease and are less likely to trigger a crisis.

Correct Answer: D

Rationale: The correct answer is D: Leucovorin. Leucovorin is given during methotrexate therapy to protect normal cells by acting as a rescue agent that helps to reduce the toxic effects of methotrexate. It works by enhancing the efficacy of methotrexate in cancer cells while reducing its toxicity in normal cells. Probenecid (A) is not used to protect normal cells during methotrexate therapy. Cytarabine (B) and Thioguanine (C) are other chemotherapeutic agents and are not typically given to protect normal cells during methotrexate therapy.