A jaundiced client has just been diagnosed with stage IV pancreatic cancer. The nurse anticipates the client will display which clinical manifestation?
Clay-colored stools
Hematuria
Pale dilute urine
Weight gain
The Correct Answer is A
A. Stage IV pancreatic cancer often leads to bile duct obstruction, causing decreased bile flow into the intestines. This results in clay-colored stools due to the absence of bile pigments.
B. Hematuria, or blood in the urine, is not a common symptom of pancreatic cancer, even in advanced stages. It is more associated with conditions affecting the urinary system.
C. Jaundice causes dark, concentrated urine rather than pale, dilute urine due to the accumulation of bilirubin in the bloodstream, which is excreted through the kidneys.
D. Weight loss, rather than weight gain, is a common manifestation in clients with advanced pancreatic cancer due to malabsorption and cachexia.
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Correct Answer is C
Explanation
A. Using a commercial medicine to remove a corn is not recommended, as it can cause skin damage and infection; diabetic clients should seek professional care for such issues.
B. Soaking feet daily in cool water can lead to skin maceration and should generally be avoided; it is better to wash and dry feet gently.
C. Utilizing a mirror to examine the soles of the feet indicates proper awareness and self-care, as diabetic clients need to monitor for any injuries or changes that could lead to complications.
D. Cutting nails in a concave manner is incorrect; nails should be cut straight across to prevent ingrown toenails.
Correct Answer is ["A","D","E"]
Explanation
A. Encouraging the use of an incentive spirometer helps prevent respiratory complications and promotes lung expansion, thereby reducing the risk of infection, particularly pneumonia.
B. While early mobilization is important for recovery, assisting the client out of bed on post-operative day 1 may not be appropriate depending on the patient's condition; this option is not directly related to infection prevention.
C. Repositioning every four hours is important for pressure ulcer prevention but does not directly impact infection risk; more frequent repositioning may be necessary to ensure adequate skin integrity and circulation.
D. Utilizing aseptic technique while changing the dressing is crucial for preventing infection at the surgical site, making this a vital intervention.
E. Maintaining TEDS (thromboembolic deterrent stockings) and SCDs (sequential compression devices) helps prevent deep vein thrombosis (DVT) and improves circulation, which can indirectly reduce infection risk by promoting better blood flow.