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1. A client undergoing radiation therapy is being taught about skin care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use a heating pad to soothe the skin
- B. I will avoid using perfumed lotions on the treated area
- C. I will apply cold compresses to the area
- D. I will scrub the area daily with soap and water
Correct answer: B
Rationale: The correct answer is B because avoiding perfumed lotions is important to prevent skin irritation after radiation therapy. Using a heating pad (A) can further damage the skin, applying cold compresses (C) may not be recommended, and scrubbing the area daily with soap and water (D) can be too harsh on the skin, leading to further irritation and damage.
2. A nurse is reviewing the laboratory results of a client who is undergoing screening for prostate cancer. The nurse should expect an elevation in which of the following laboratory values?
- A. Prostate-specific antigen (PSA)
- B. Human chorionic gonadotropin (hCG)
- C. Alpha-fetoprotein (AFP)
- D. Carcinoembryonic antigen (CEA)
Correct answer: A
Rationale: The correct answer is A: Prostate-specific antigen (PSA). PSA is a marker specifically used for prostate cancer screening. Elevated levels of PSA can indicate prostate cancer or other prostate-related issues, prompting the need for further diagnostic investigations. Choices B, C, and D are not typically associated with prostate cancer screening. Human chorionic gonadotropin (hCG) is related to pregnancy, alpha-fetoprotein (AFP) is associated with liver and germ cell tumors, and carcinoembryonic antigen (CEA) is linked to colorectal cancer.
3. What is the first intervention for a patient in shock?
- A. Administer fluids
- B. Monitor blood pressure
- C. Provide oxygen
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.
4. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?
- A. Apply counter-pressure for back pain
- B. Use deep breathing exercises
- C. Visualize the baby's head
- D. Use massage therapy
Correct answer: A
Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.
5. A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?
- A. Use abdominal breathing during physical activity
- B. Inhale quickly and deeply through the nose
- C. Use pursed-lip breathing during physical activity
- D. Breathe quickly and deeply during exercise
Correct answer: C
Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.
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