A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?
a. "Avoid getting salt water on the radiation site."
b. "Do not expose the radiation area to direct sunlight."
c. "Have a wonderful time and enjoy your vacation!"
d. "Remember you should not drink alcohol for a year."
ANS: B
The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.
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A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take?
a. Document the finding in the client's chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.
A nurse is caring for a client who experienced short-term memory loss as a result of a head injury. Which of the following statements made by the nurse regarding goal setting requires follow-up by the nurse manager?
1. "The client will certainly need frequent reorientation to the care plan goals." 2. "I will restate the goals I've created for him regularly so as to win his compli-ance." 3. "I'm not sure that his family will be able to support him with these goals but I will discuss it with them." 4. "He seems very willing to work towards achieving his goals but his condition will certainly create barriers."
Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age?
a. 1 month c. 6 to 8 months b. 3 to 4 months d. 12 months
A patient who has had a seizure is crying, saying life is over, and that working and driving will no longer be possible. Which response by the nurse is most appropriate?
a. "With good seizure control, you should be able to work and drive again." b. "Maybe the social worker can help you identify some alternative activities." c. "You may be able to work again in time; you can use public transportation." d. "You should be able to discontinue your medication within a month and return to work."