A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?
Chest pain and dyspnea.
Seizures.
Hematuria.
Swelling of the extremities.
The Correct Answer is B
Choice A rationale
Chest pain and dyspnea are concerning symptoms but are not the most immediate manifestations to report in a client undergoing radiation therapy for brain cancer. These symptoms could be related to other conditions and require further evaluation.
Choice B rationale
Seizures are the most immediate manifestation to report because they indicate increased intracranial pressure or other neurological complications related to brain cancer and radiation therapy. Seizures require prompt medical intervention to prevent further complications.
Choice C rationale
Hematuria is a concerning symptom but is not the most immediate manifestation to report in this context. It could be related to other conditions and requires further evaluation.
Choice D rationale
Swelling of the extremities is a concerning symptom but is not the most immediate manifestation to report in this context. It could be related to other conditions and requires further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While chest pain can occur after pacemaker insertion, it is not the primary concern immediately following the procedure. The nurse should monitor for more critical complications such as arrhythmias, which can indicate pacemaker malfunction or lead displacement.
Choice B rationale
Infection is a potential complication after pacemaker insertion, but it typically develops over a longer period. Immediate monitoring should focus on acute complications such as arrhythmias.
Choice C rationale
Bleeding is a concern after any surgical procedure, including pacemaker insertion. However, the primary immediate concern is monitoring for arrhythmias, which can indicate issues with the pacemaker’s function.
Choice D rationale
Arrhythmias are the primary concern immediately following pacemaker insertion. The nurse should monitor the client for any irregular heart rhythms, which can indicate pacemaker malfunction or lead displacement. Prompt identification and management of arrhythmias are crucial to ensure the pacemaker is functioning correctly.
Correct Answer is D
Explanation
Choice A rationale
Including fluoridated water in the toddler’s diet does not prevent iron deficiency anemia.
Choice B rationale
Administering fat-soluble vitamins daily is not a method of preventing iron deficiency anemia.
Choice C rationale
Limiting intake of high-protein foods is not related to preventing iron deficiency anemia.
Choice D rationale
Avoiding a diet that consists primarily of milk is recommended because excessive milk intake can interfere with iron absorption and lead to iron deficiency anemia.
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