The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
Applies prescribed lotions to the radiation site.
Washes the radiation site with antibacterial soap and water.
Wears clothing to cover the radiation site.
Dries the area with patting motions after taking a shower.
The Correct Answer is B
Choice A reason: Applying prescribed lotions to the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help moisturize and protect the skin from irritation and breakdown. The client should follow the instructions of the health care provider regarding the type and frequency of lotion application. Therefore, this choice does not indicate a need for further teaching.
Choice B reason: Washing the radiation site with antibacterial soap and water is a bad action for a client with cancer receiving external beam radiation, because it can cause dryness, inflammation, and infection of the skin. The client should use mild soap and water or saline solution to gently cleanse the area without rubbing or scrubbing. Therefore, this choice indicates a need for further teaching.
Choice C reason: Wearing clothing to cover the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help shield the skin from sun exposure and friction. The client should wear loose-fitting, soft, cotton clothing that does not irritate or constrict the area. Therefore, this choice does not indicate a need for further teaching.
Choice D reason: Drying the area with patting motions after taking a shower is a good action for a client with cancer receiving external beam radiation, because it can help prevent trauma and infection of the skin. The client should avoid rubbing or scratching the area or using hair dryers or heating pads on it. Therefore, this choice does not indicate a need for further teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Weight gain of 2 pounds (0.91 kg) in one day is a sign of fluid retention, which occurs in SIADH due to excessive secretion of antidiuretic hormone (ADH). ADH causes the kidneys to reabsorb water and reduce urine output, leading to hyponatremia and hypervolemia.
Choice B reason: Fremitus over the chest wall is a sign of increased vibration or air movement in the lungs, which can indicate pneumonia, bronchitis, or pleural effusion. These are not related to SIADH, but may be complications of head injury or fluid overload.
Choice C reason: Serum sodium of 150 mEq/L (150 mmol/L) is a sign of hypernatremia, which is a high level of sodium in the blood. This is the opposite of what happens in SIADH, where sodium levels are low due to dilution by excess water.
Choice D reason: Urine specific gravity of 1.004 is a sign of diluted urine, which indicates low concentration of solutes in the urine. This is also the opposite of what happens in SIADH, where urine is concentrated and has a high specific gravity.
Correct Answer is []
Explanation
Focused assesment area : Neurological
The correct answer is B. Speaks in short sentences.
Choice A: Drinks with repetitive cough. This is an incorrect answer because it indicates that the patient has difficulty swallowing, which is a common complication of ischemic stroke. Swallowing problems can lead to aspiration pneumonia, dehydration, and malnutrition. Therefore, this finding does not indicate effective early intervention for ischemic stroke¹.
Choice B: Speaks in short sentences. This is a correct answer because it indicates that the patient's speech has improved from being garbled to being intelligible. Speech impairment is a common symptom of ischemic stroke, especially when the left hemisphere of the brain is affected. Early intervention with thrombolytic therapy or mechanical thrombectomy can restore blood flow to the affected brain tissue and reduce the extent of damage². Therefore, this finding indicates effective early intervention for ischemic stroke.
Choice C: Decorticate posturing. This is an incorrect answer because it indicates that the patient has severe brain damage and is in a state of coma. Decorticate posturing is a type of abnormal posture that occurs when the upper limbs flex and the lower limbs extend in response to pain or stimulation. It indicates damage to the cerebral hemispheres or the internal capsule³. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Focused assesment area : Muscoskeletal
The correct answer is B. Ambulates with a walker.
Choice A: Flaccidity of left arm. This is an incorrect answer because it indicates that the patient has weakness or paralysis of the left arm, which is a common symptom of ischemic stroke. Flaccidity is the absence of muscle tone or resistance to passive movement. It indicates damage to the motor cortex or the corticospinal tract. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Choice B: Ambulates with a walker. This is a correct answer because it indicates that the patient has regained some mobility and independence after the ischemic stroke. Ambulation is the ability to walk or move from one place to another. Early intervention with physical therapy and rehabilitation can help improve the patient's functional recovery and prevent complications such as deep vein thrombosis, pressure ulcers, and contractures. Therefore, this finding indicates effective early intervention for ischemic stroke.
Choice C: Passive range of motion on left leg. This is an incorrect answer because it indicates that the patient has limited or no voluntary movement of the left leg, which is another common symptom of ischemic stroke. Passive range of motion is the movement of a joint or limb by an external force, such as a therapist or a caregiver. It indicates damage to the motor cortex or the corticospinal tract. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Focused assesment area : Psychosocial
The correct answer is B. Tearful sharing of stories.
Choice A: Fits of laughter. This is an incorrect answer because it indicates that the patient has inappropriate emotional responses, which is a common complication of ischemic stroke. Inappropriate emotional responses are sudden and uncontrollable episodes of laughing or crying that are out of context or disproportionate to the situation. They indicate damage to the brain regions that regulate emotions, such as the frontal lobe, the thalamus, or the brainstem. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Choice B: Tearful sharing of stories. This is a correct answer because it indicates that the patient has improved social and emotional functioning after the ischemic stroke. Tearful sharing of stories is a normal and healthy way of expressing emotions and coping with stress. It also shows that the patient has preserved memory and language skills, which are often impaired by ischemic stroke. Early intervention with psychological support and counseling can help the patient deal with the emotional impact of stroke and improve their quality of life. Therefore, this finding indicates effective early intervention for ischemic stroke.
Choice C: Angry outburst. This is an incorrect answer because it indicates that the patient has mood disturbances, which is another common complication of ischemic stroke. Mood disturbances are changes in the patient's emotional state, such as depression, anxiety, irritability, or aggression. They indicate damage to the brain regions that regulate mood, such as the frontal lobe, the amygdala, or the hippocampus. Therefore, this finding does not indicate effective early intervention for ischemic stroke.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.