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A home health nurse is collecting data on an adolescent who has cystic fibrosis. The child expresses concern about experiencing increasing episodes of respiratory distress and asks the nurse for insight into the possible reasons. Which of the following responses should the nurse make?

"As a nurse, I can't diagnose what is causing you to have worsening symptoms. However, I will relay this information to your healthcare provider so they can determine what should happen next."

“If you are experiencing worsening respiratory distress, we must get you to the emergency department immediately.”

“It sounds like you may be concerned that your condition could be getting worse. That can be scary tell me more about what you have been experiencing."

"As you know, cystic fibrosis is a respiratory disease. Increased respiratory distress is a characteristic symptom of this disorder."

Answer and Explanation

The Correct Answer is C

A. "As a nurse, I can't diagnose what is causing you to have worsening symptoms. However, we will relay this information to your healthcare provider so they can determine what should happen next." While it is true that nurses cannot diagnose, this response does not address the adolescent’s concerns or encourage them to share more information about their symptoms.

B. "If you are experiencing worsening respiratory distress, we must get you to the emergency department immediately." This response may create unnecessary alarm without first assessing the severity of the symptoms. While severe distress requires urgent care, the nurse should first gather more information.

C. "It sounds like you may be concerned that your condition could be getting worse. That can be scary—tell me more about what you have been experiencing." This is correct because it acknowledges the adolescent's emotions, encourages open communication, and allows the nurse to gather more information before determining the appropriate course of action.

D. "As you know, cystic fibrosis is a respiratory disease. Increased respiratory distress is a characteristic symptom of this disorder." While this statement is factually correct, it dismisses the adolescent’s concern instead of providing reassurance, emotional support, and further assessment.

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Correct Answer is B

Explanation

A. Leukocytes. Leukocytes (white blood cells) are involved in the immune response and are not the primary cells affected in testicular cancer. Cancers of leukocytes include leukemia and lymphoma, not testicular cancer.

B. Germ cells. This is correct. Testicular cancer most commonly arises from germ cells, which are the cells responsible for producing sperm. Germ cell tumors (GCTs) account for over 90% of testicular cancers, including seminomas and non-seminomas.

C. Epithelial cells. Epithelial cells line various tissues and organs, but they are not the primary source of testicular cancer. Epithelial cell cancers, like carcinomas, more commonly affect the skin, lungs, and digestive tract.

D. Lymphocytes. Lymphocytes are a type of white blood cell involved in the immune system. Testicular lymphoma can occur but is rare compared to germ cell tumors, which are the most frequent type of testicular cancer in adolescents and young adults.

A. Aspirin B. Corticosteroid cream C. Oral antihistamine D. Oral antibiotics

Correct Answer is C

Explanation

A. Aspirin. Aspirin should never be given to a child with chickenpox due to the risk of Reye's syndrome, a rare but serious condition that can cause liver and brain damage when aspirin is used during viral infections.

B. Corticosteroid cream. While corticosteroids reduce inflammation, they are not recommended for chickenpox because they can suppress the immune response and potentially worsen the infection.

C. Oral antihistamine. Antihistamines such as diphenhydramine help relieve severe itching, which is a common symptom of chickenpox. Reducing itchiness can also help prevent scratching that may lead to skin infections and scarring.

D. Oral antibiotics. Chickenpox is caused by the varicella-zoster virus, so antibiotics are not needed unless a secondary bacterial infection (such as impetigo) develops from scratching the lesions.

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A home health nurse is collecting data on an adolescent who has cystic fibrosis. The child expresses concern about experiencing increasing episodes of respiratory distress and asks the nurse for insight into the possible reasons. Which of the following responses should the nurse make?

Nursing Test Bank

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Correct Answer is B

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Correct Answer is C

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