Question

The nurse is caring for a client with internal radiation implants (brachytherapy) for prostate cancer. Which safety measure should the nurse implement?

Answer 1

Correct Answers:

Wear a dosimeter film badge when providing care.

Rationale :

💎 Radiation safety is essential in protecting healthcare staff from unnecessary exposure when caring for clients with internal radiation implants (brachytherapy).

💎 A dosimeter film badge measures the cumulative radiation exposure of the nurse, ensuring it stays within safe occupational limits.

💎 Nurses should also limit time spent in the client’s room, maintain distance from the source, and use lead shielding when appropriate.

💎 The client should remain in a private room with warning signage, but negative air pressure or isolation is not required unless infection precautions apply.

💎 Pregnant staff or visitors should not enter the room due to potential fetal harm from radiation exposure.

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Answer 2

Correct Answers:

Decreased lipase

Rationale :

🔷 In acute pancreatitis, both amylase and lipase levels rise due to pancreatic inflammation.

🔷 As the condition improves, lipase levels decrease, indicating reduced inflammation and improved pancreatic function.

🔷 Amylase may normalize earlier, but lipase is a more specific and reliable marker for pancreatic recovery.

🔷 Other signs of improvement include decreased pain, normal appetite, and resolution of nausea/vomiting.

🔷 Ongoing monitoring of enzyme trends helps evaluate treatment effectiveness and healing progress.

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Answer 3

Correct Answers:

Severe testicular pain

Rationale :

💠 Severe, sudden testicular pain is the hallmark of testicular torsion, a surgical emergency requiring immediate intervention to restore blood flow.

💠 Torsion causes ischemia due to twisting of the spermatic cord, which can lead to testicular necrosis within hours if untreated.

💠 Prompt surgical detorsion and fixation are necessary to preserve fertility and prevent tissue death.

💠 Swelling or redness may occur later, but the pain is the most urgent and concerning symptom.

💠 Delays in treatment beyond 6 hours significantly reduce the chance of testicular salvage.

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Answer 4

Correct Answers:

Provide emotional support for the family.
Improve the quality of the client's remaining life.
Provide comfort and support during the dying process.

Rationale :

⭐ Provide emotional support for the family Families experience anticipatory grief; offering emotional and psychosocial support helps them cope and facilitates acceptance.

⭐Improve the quality of the client's remaining life The focus of end-of-life care is on quality of life, not prolongation. Comfort, dignity, and symptom control are key goals.

⭐ Provide comfort and support during the dying process Ensuring pain relief, peace, and comfort through palliative measures supports a peaceful death and honors the client’s wishes.

⭐ Additional Note: Frequent assessments or curative decisions are not consistent with the goals of palliative/end-of-life care.

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Answer 5

Correct Answers:

Monitor the client's liver function tests regularly.

Rationale :

🔶 Jaundice in a client with hepatitis C signals hepatic inflammation or dysfunction, requiring close monitoring of liver function tests (ALT, AST, bilirubin, albumin, PT/INR).

🔶 Regular monitoring helps evaluate the extent of liver damage and the effectiveness of treatment.

🔶 Clients should avoid hepatotoxic drugs like acetaminophen and alcohol to prevent further injury.

🔶 Adequate hydration and balanced rest are encouraged, but total inactivity is not necessary.

🔶 Education about disease transmission prevention is also a key nursing responsibility.

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Answer 6

Correct Answers:

Have the client use a picture board to express their needs.

Rationale :

💎 Expressive aphasia (Broca’s aphasia) occurs when a client understands language but has difficulty expressing themselves verbally.

💎 Providing a picture or communication board helps the client express needs nonverbally, reducing frustration and promoting autonomy.

💎 The nurse should speak slowly, use simple words, and allow extra time for the client to respond.

💎 Completing the client’s sentences or guessing words can increase anxiety and reduce confidence.

💎 Nodding without understanding may lead to miscommunication and unmet needs.

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Answer 7

Correct Answers:

Monitor Glasgow Coma Scale (GCS) trends.
Pad the side rails of the client's bed.
Administer prescribed pain medications.
Educate the family about decreasing stimulation.

Rationale :

🔷Monitor Glasgow Coma Scale (GCS) trends Continuous GCS assessment helps detect early neurological deterioration and guides interventions for increased intracranial pressure (ICP).

🔷 Pad the side rails of the client's bed Clients with TBI and elevated ICP are at risk for seizures; padding prevents injury during unexpected convulsions.

🔷Administer prescribed pain medications Pain can increase ICP by elevating blood pressure and sympathetic stimulation. Administering analgesics reduces intracranial stress and promotes comfort.

🔷Educate the family about decreasing stimulation Excessive noise, bright lights, or frequent visitors can raise ICP. Family education on providing a calm, quiet environment supports cerebral recovery.

🔷 The neck should not be flexed as it impedes venous drainage and elevates ICP.

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Answer 8

Correct Answers:

History of Epstein Barr virus

Rationale :

💠 Epstein–Barr virus (EBV) infection is a known risk factor for acute lymphocytic leukemia (ALL) due to its association with abnormal lymphocyte proliferation.

💠 Other risk factors include radiation exposure, Down syndrome, and genetic predisposition.

💠 ALL primarily affects children under 15 years, not adults in their 30s.

💠 Males have a slightly higher incidence than females.

💠 Early recognition is essential because ALL is aggressive but highly treatable with timely therapy.

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Answer 9

Correct Answers:

The client will remain free from injuries.

Rationale :

🔶 Clients with altered cognition from chronic alcohol use are at increased risk for falls, confusion, and impaired judgment, making injury prevention the top priority.

🔶 Safety measures such as bed alarms, low beds, and supervised ambulation should be implemented.

🔶 Other goals, like airway maintenance or infection control, are important but secondary unless acute compromise exists.

🔶 Consistent orientation and environmental safety help reduce accidents.

🔶 Long-term care includes alcohol cessation support and cognitive rehabilitation.

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Answer 10

Correct Answers:

Sudden severe headache

Rationale :

💠 A sudden, severe (“worst in life”) headache indicates possible hemorrhagic stroke or ruptured aneurysm, a life-threatening emergency requiring immediate evaluation.

💠 Rapid onset headache often results from bleeding into the brain, leading to increased ICP and potential herniation.

💠 Other CVA symptoms like weakness or slurred speech are concerning, but sudden severe pain signifies acute intracranial pathology.

💠 Emergency management includes CT scan, neurological monitoring, and blood pressure control to prevent rebleeding.

💠 Timely recognition improves survival and neurological outcomes.

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Exam W8 NR325.NR330 Exam 2

No.

1 :
The nurse is caring for a client with internal radiation implants (brachytherapy) for prostate cancer. Which safety measure should the nurse implement?

2 :
The nurse evaluates the plan of care for a client with acute pancreatitis. What finding indicates to the nurse that the client's condition is improving?

3 :
The nurse assesses a client with suspected testicular torsion. What finding should the nurse identify as most concerning?

4 :
The nurse plans care for a client with a terminal disease at the end of life. What action(s) should the nurse include in the care of this client? Select all that apply.

5 :
During a routine assessment, a nurse notes that a client with hepatitis C has jaundice. What action should the nurse include in the client's plan of care?

6 :
The nurse is caring for a client with expressive aphasia after a cerebrovascular accident. What action should the nurse take to facilitate effective communication with the client?

7 :
The nurse is planning care for a client with a traumatic brain injury (TBI) and increased intracranial pressure. Which action(s) should the nurse include in the plan of care? Select all that apply.

8 :
What is a risk factor for developing acute lymphocytic leukemia (ALL)?

9 :
The nurse plans care for a client with altered cognition related to chronic alcohol use. What goal should the nurse prioritize in the client's care plan?

10 :
The nurse assesses a client with a suspected cerebrovascular accident (CVA). Which finding is most concerning to the nurse?

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Exam W8 NR325.NR330 Exam 2

No.

1 : The nurse is caring for a client with internal radiation implants (brachytherapy) for prostate cancer. Which safety measure should the nurse implement?

2 : The nurse evaluates the plan of care for a client with acute pancreatitis. What finding indicates to the nurse that the client's condition is improving?

3 : The nurse assesses a client with suspected testicular torsion. What finding should the nurse identify as most concerning?

4 : The nurse plans care for a client with a terminal disease at the end of life. What action(s) should the nurse include in the care of this client? Select all that apply.

5 : During a routine assessment, a nurse notes that a client with hepatitis C has jaundice. What action should the nurse include in the client's plan of care?

6 : The nurse is caring for a client with expressive aphasia after a cerebrovascular accident. What action should the nurse take to facilitate effective communication with the client?

7 : The nurse is planning care for a client with a traumatic brain injury (TBI) and increased intracranial pressure. Which action(s) should the nurse include in the plan of care? Select all that apply.

8 : What is a risk factor for developing acute lymphocytic leukemia (ALL)?

9 : The nurse plans care for a client with altered cognition related to chronic alcohol use. What goal should the nurse prioritize in the client's care plan?

10 : The nurse assesses a client with a suspected cerebrovascular accident (CVA). Which finding is most concerning to the nurse?

1 :
The nurse is caring for a client with internal radiation implants (brachytherapy) for prostate cancer. Which safety measure should the nurse implement?

2 :
The nurse evaluates the plan of care for a client with acute pancreatitis. What finding indicates to the nurse that the client's condition is improving?

3 :
The nurse assesses a client with suspected testicular torsion. What finding should the nurse identify as most concerning?

4 :
The nurse plans care for a client with a terminal disease at the end of life. What action(s) should the nurse include in the care of this client? Select all that apply.

5 :
During a routine assessment, a nurse notes that a client with hepatitis C has jaundice. What action should the nurse include in the client's plan of care?

6 :
The nurse is caring for a client with expressive aphasia after a cerebrovascular accident. What action should the nurse take to facilitate effective communication with the client?

7 :
The nurse is planning care for a client with a traumatic brain injury (TBI) and increased intracranial pressure. Which action(s) should the nurse include in the plan of care? Select all that apply.

8 :
What is a risk factor for developing acute lymphocytic leukemia (ALL)?

9 :
The nurse plans care for a client with altered cognition related to chronic alcohol use. What goal should the nurse prioritize in the client's care plan?

10 :
The nurse assesses a client with a suspected cerebrovascular accident (CVA). Which finding is most concerning to the nurse?