Nursing Elites

1. A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?

• A. Risk for Ineffective Tissue Perfusion
• B. Risk for Imbalanced Fluid Volume
• C. Risk for Ineffective Breathing Pattern
• D. Risk for Ineffective Thermoregulation

Correct answer: A

Rationale: Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by an abnormally high platelet count, which increases the risk of hypercoagulation and thrombosis (blood clot formation). These clots can impair blood flow to tissues, leading to ineffective tissue perfusion. Thrombotic events, such as strokes, deep vein thrombosis, or myocardial infarctions, are common complications of ET, making Risk for Ineffective Tissue Perfusion the most critical nursing diagnosis to prioritize. The goal of nursing interventions will be to prevent clot formation and ensure adequate blood flow to tissues.

2. A nurse is planning care for a patient with leukemia who has been experiencing severe fatigue. What is the most appropriate intervention to include in the care plan?

• A. Encouraging the patient to remain in bed
• B. Scheduling frequent rest periods
• C. Providing a high-calorie diet
• D. Administering blood transfusions

Correct answer: B

Rationale: In patients with leukemia, severe fatigue is a common symptom due to factors such as anemia, the disease process itself, and the effects of treatments like chemotherapy. The most appropriate intervention is to schedule frequent rest periods to help manage fatigue while encouraging a balance between rest and activity. This approach allows the patient to conserve energy for essential tasks and prevent exhaustion, without promoting complete inactivity, which can lead to deconditioning.

3. In an adult patient, which assessment finding is considered diagnostic of Hodgkin lymphoma?

• A. Schwann cells
• B. Reed-Sternberg cells
• C. Lewy bodies
• D. Loops of Henle

Correct answer: B

Rationale: The correct answer is B: Reed-Sternberg cells. In Hodgkin lymphoma, the presence of Reed-Sternberg cells in lymph node biopsy is diagnostic. These cells are large, atypical cells originating from B-lymphocytes. They are distinctive in appearance and are key to diagnosing Hodgkin lymphoma. Choices A, C, and D are incorrect because Schwann cells are related to nerve function, Lewy bodies are associated with Parkinson's disease, and Loops of Henle are structures in the kidney, none of which are specific to Hodgkin lymphoma.

4. A client is admitted to the hospital with a suspected diagnosis of Hodgkin’s disease. Which assessment finding would the nurse expect to note specifically in the client?

• A. Fatigue
• B. Weakness
• C. Weight gain
• D. Enlarged lymph nodes

Correct answer: D

Rationale: Hodgkin’s disease (Hodgkin’s lymphoma) is a type of cancer that originates in the lymphatic system, particularly affecting the lymph nodes. A hallmark sign of Hodgkin’s disease is the painless enlargement of lymph nodes, often in the neck, armpit, or groin. These enlarged lymph nodes are typically firm and rubbery to the touch. This is one of the most distinctive and common early signs that healthcare providers look for when diagnosing the disease.

5. The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

• A. At the onset of menstruation
• B. Every month during ovulation
• C. Weekly at the same time of day
• D. 1 week after menstruation begins

Correct answer: D

Rationale: The optimal time for performing a breast self-examination (BSE) is about one week after menstruation begins, as this is when the breasts are least likely to be swollen, tender, or affected by hormonal changes. Hormonal fluctuations during the menstrual cycle can cause temporary changes in breast tissue, such as swelling, lumpiness, or tenderness, which may make it more difficult to detect any unusual lumps or changes. Conducting the examination during this period ensures that the breasts are in their natural state, making it easier to notice any abnormalities.

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