Which of the following instructions should a nurse give a client with Hodgkin's disease who is at risk of impaired skin integrity?

Correct Answer: B

Rationale: The correct answer is B) Use mild soap. When dealing with a client with Hodgkin's disease at risk of impaired skin integrity, it's important to recommend using mild soap to prevent skin irritation and damage. Strong or harsh soaps can strip the skin of its natural oils, leading to dryness and increased susceptibility to breakdown. A) Do not trim nails - While it's important to avoid cuts or injuries that can lead to infection, regular nail care is still essential for hygiene and overall skin health. Trimming nails carefully and keeping them clean is necessary. C) Rub skin dry - Rubbing the skin dry vigorously can further irritate and damage the skin, especially in individuals with compromised skin integrity. It's recommended to pat the skin gently to dry to avoid friction and trauma. D) Keep the neck in midline - While proper positioning is crucial for clients with certain medical conditions, maintaining the neck in midline does not directly address the issue of impaired skin integrity. This instruction is not as relevant to preventing skin breakdown. Educational context: Understanding the specific needs of clients with Hodgkin's disease is essential for nurses to provide comprehensive care. Educating clients on proper skin care practices can help prevent complications and promote overall well-being. By choosing the right interventions, nurses can enhance the quality of life for individuals undergoing treatment for Hodgkin's disease.

Correct Answer: D

Rationale: The correct answer is D) Epstein-Barr virus. This virus is responsible for causing mononucleosis, also known as the "kissing disease." Mononucleosis is characterized by symptoms such as fever, sore throat, swollen lymph nodes, and fatigue. The Epstein-Barr virus is commonly spread through saliva, hence its association with kissing. Option A) Elephantiasis is caused by parasitic worms transmitted through mosquito bites and leads to severe swelling of body parts, not related to mononucleosis. Option B) Reed-Sternberg cells are characteristic of Hodgkin's lymphoma, a type of lymphoma, not mononucleosis. Option C) Lymphogranulomatosis is an outdated term for Hodgkin's lymphoma. This term is no longer commonly used in medical practice. Understanding the etiology of infections such as mononucleosis is crucial for healthcare professionals, especially nurses who may encounter and care for patients with these conditions. Knowing the correct causative agent helps in appropriate diagnosis, treatment, and patient education. Additionally, understanding the differences between similar-sounding conditions like mononucleosis and Hodgkin's lymphoma is essential for accurate clinical assessment and management.

Correct Answer: D

Rationale: The correct answer is D) The symptoms of pacemaker malfunction. This teaching need assumes the highest priority because recognizing and understanding the symptoms of pacemaker malfunction is crucial for the patient's safety and well-being. Knowing the signs of malfunction such as dizziness, palpitations, chest pain, or fainting allows the patient to seek immediate medical attention, potentially preventing serious complications or even death. Option A) How to take his pulse daily is important but not as critical as recognizing symptoms of pacemaker malfunction. Monitoring pulse is a routine activity, whereas identifying malfunction symptoms is a matter of urgent concern. Option B) The importance of wearing a medical-alert bracelet is also essential but does not take precedence over knowing the symptoms of malfunction. While the bracelet provides important information in case of emergencies, knowing when to seek help due to malfunction is more pressing. Option C) The positive aspects of life with a pacemaker is a valuable topic for overall patient education but is not as urgent as understanding the signs of malfunction. Patient education on lifestyle adjustments and coping mechanisms can be addressed at a later time once the immediate safety concerns are covered. In an educational context, prioritizing teaching needs based on urgency and potential impact on patient outcomes is crucial in healthcare settings. By focusing on the most critical information first, educators can ensure that patients are equipped with the knowledge needed to manage their health effectively and respond appropriately to emergencies.

Correct Answer: D

Rationale: Rationale: The correct answer is D) Tissue hypoxia due to reduced capacity to carry O2. In all types of anemia, the major physiologic effect that underlies the resulting symptoms is the reduced capacity of the blood to carry oxygen. Anemia is characterized by a decrease in the number of red blood cells or hemoglobin levels, leading to decreased oxygen-carrying capacity. This results in tissue hypoxia, where the body's cells do not receive an adequate supply of oxygen, leading to symptoms such as fatigue, weakness, shortness of breath, and pale skin. Option A) Increased hemoglobin in the blood is incorrect because anemia is characterized by a decrease, not an increase, in hemoglobin levels. Option B) Urobilinogen in the blood and urine is unrelated to the major physiologic effect of anemia and is not a characteristic finding in anemia. Option C) Silent bleeding into the intestinal tract is a possible cause of anemia, specifically iron-deficiency anemia, but it does not directly address the major physiologic effect underlying the resulting symptoms. Educational Context: Understanding the major physiologic effect of anemia is essential for healthcare professionals, especially in fields like hematology and nursing. Recognizing the link between reduced oxygen-carrying capacity and the symptoms of anemia helps in diagnosing and managing patients with various types of anemia. By grasping this concept, healthcare providers can provide appropriate interventions to address tissue hypoxia and improve the quality of life for individuals affected by anemia.

Correct Answer: D

Rationale: The correct answer is D) vitamin B12 and disturbed nervous system functioning. Understanding the relationship between vitamin B12 and disturbed nervous system functioning is crucial for Mrs. Young as vitamin B12 plays a key role in maintaining the health of nerve cells and producing myelin, a substance that protects nerve fibers. Deficiency in vitamin B12 can lead to neurological symptoms such as numbness, tingling, and memory problems. Option A) chemotherapy and alopecia is incorrect as chemotherapy is commonly associated with alopecia (hair loss), not vitamin B12. Option B) drinking a quart of milk daily and preventing iron deficiency is incorrect as milk is not a primary source of iron, and iron deficiency is not directly related to milk consumption. Option C) nitroglycerin and the relief of angina is incorrect as nitroglycerin is a medication used to relieve chest pain (angina) by dilating blood vessels, not related to vitamin B12. Educationally, understanding the relationship between specific nutrients like vitamin B12 and their impact on bodily functions is essential for patients to make informed decisions about their health, especially when managing conditions that are influenced by nutritional factors. This knowledge empowers individuals to take proactive steps in maintaining their well-being and seeking appropriate interventions when necessary.