nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

Examine the skin for generalized urticaria.

Observe for signs of infection.

Review laboratory test results for low hemoglobin.

Monitor the mouth for signs of xerostomia

Answer and Explanation

The Correct Answer is B

A. Urticaria (hives) is not a common side effect of radiation therapy. The skin should be examined for localized radiation-induced skin changes, such as erythema or dryness, rather than generalized urticaria.
B. Radiation therapy can weaken the immune system, increasing the risk of infection. The nurse should monitor for signs of infection, especially in areas affected by radiation, as the skin and mucous membranes can become more vulnerable.
C. Low hemoglobin is not a direct or immediate concern related to radiation therapy for lung cancer. However, it could occur if the patient experiences bone marrow suppression, but this is not typically the primary concern for radiation therapy to the lung.
D. Xerostomia (dry mouth) is more commonly associated with radiation therapy to the head and neck area. Radiation to the lungs generally does not affect salivary glands, so monitoring for xerostomia is not necessary in this case.

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Correct Answer is B

Explanation

A. A widening pulse pressure (the difference between systolic and diastolic blood pressure) can be a sign of increasing intracranial pressure (ICP), but it typically occurs later in the progression of ICP. Early signs of increased ICP are often more subtle and include changes in behavior and consciousness.

B. One of the earliest signs of increased ICP is altered mental status or behavioral changes, such as increasing restlessness or agitation. As pressure builds inside the skull, it affects the brain's ability to function normally, leading to these early signs. Restlessness may indicate that the brain is becoming less able to maintain normal function due to the increasing pressure.

C. A decrease in pulse rate may occur later in the course of increased ICP, particularly with severe increases in pressure. However, early signs typically involve changes in consciousness and mental status rather than changes in vital signs like heart rate.

D. Dilated and fixed pupils are a late sign of increased ICP and usually indicate significant brain herniation or severe neurological compromise. While they are serious and require immediate attention, they do not typically occur at the early stages of increased ICP.

A. Malignant melanoma B. Actinic keratosis C. squamous cell carcinoma D. Basal cell carcinoma

Correct Answer is D

Explanation

A. Malignant melanoma often appears as an irregularly shaped lesion with variegated colors (brown, black, red, white, or blue) and uneven borders. It is usually larger and more aggressive than the lesion described.
B. Actinic keratosis typically presents as rough, scaly patches on sun-exposed areas and is considered a precancerous lesion rather than a form of skin cancer itself.
C. Squamous cell carcinoma usually appears as a firm, red nodule or a scaly, crusted lesion that may ulcerate. It is more likely to be aggressive than basal cell carcinoma.
D. Basal cell carcinoma commonly presents as a small, raised, flesh-colored or pink lesion with pearly or translucent borders, which fits the description provided. It is the most common and least aggressive type of skin cancer.

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nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with an acute head injury. Which assessment finding would first alert the nurse that the client is developing an Increase in intracranial pressure?

Correct Answer is B

Explanation

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Correct Answer is D

Explanation

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