Which of the following nursing interventions ensures that a client with Hodgkin's disease remains free of infection?

Correct Answer: B

Rationale: The correct answer is B) Practice conscientious hand washing. This nursing intervention is crucial in ensuring that a client with Hodgkin's disease remains free of infection because these individuals often have compromised immune systems due to the disease and its treatments. Proper hand hygiene helps prevent the spread of pathogens that could lead to infections, which can be particularly dangerous for immunocompromised patients like those with Hodgkin's disease. Option A) Apply ice to the skin for brief periods is not directly related to infection prevention in this context. While it may provide comfort for certain symptoms, it does not address the risk of infection that is the primary concern for these patients. Option C) Provide cool sponge baths is also not directly related to infection prevention. While maintaining good hygiene is important, the key focus for infection control lies in practices like hand washing that directly reduce the risk of introducing harmful pathogens to the patient. Option D) Use cotton gloves is not as effective as proper hand washing in preventing infection transmission. While gloves can be useful in certain situations, they are not a substitute for thorough hand hygiene practices, which are essential for reducing the risk of infections in patients with compromised immune systems like those with Hodgkin's disease. In an educational context, it is important for nurses to understand the rationale behind each intervention to provide safe and effective care to their patients. By emphasizing the significance of hand washing in infection control for immunocompromised individuals, nurses can help protect these vulnerable patients from potential harm and improve their overall quality of care.

Correct Answer: C

Rationale: The correct answer is C) Place the client in high Fowler's position. Placing the client in high Fowler's position, with the head of the bed elevated at 90 degrees, helps to reduce pressure on the trachea caused by enlarged cervical lymph nodes in Hodgkin's lymphoma. This position also promotes increased lung expansion and improved air exchange by allowing the diaphragm to descend more freely, thereby enhancing respiratory function. Option A) Encouraging the use of incentive spirometry is a beneficial intervention for promoting deep breathing exercises and improving lung ventilation, but it does not directly address the issue of tracheal pressure caused by enlarged lymph nodes. Option B) Monitoring pulse oximetry and maintaining oxygen saturation at 90% or greater is important for assessing oxygenation status but does not directly alleviate tracheal pressure or improve lung expansion. Option D) Keeping the environment quiet and free of distraction is essential for promoting a restful and healing environment for the client but does not address the physiological need for improved respiratory function in this situation. Educationally, understanding the rationale behind positioning in high Fowler's is crucial for nurses caring for clients with respiratory issues like Hodgkin's lymphoma. It helps students grasp the importance of proper positioning in enhancing respiratory mechanics and ensuring adequate oxygenation for clients with compromised airways. This case underscores the significance of evidence-based nursing interventions in promoting optimal patient outcomes.

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.