NCLEX-RN QUESTION
AND ANSWERS WITH
RATIONALES 2023
Physiological Integrity: Physiological Adaptation Questions
1. Your client is receiving brachytherapy. What nursing intervention should you implement for this client?
A.Exclude pregnant visitors from the client’s room.
B.Place the client in a negative pressure room.
C.Have all visitors wear protective masks and boots.
D.All of the above
Correct Response: A
You would exclude all pregnant visitors from the client’s room in order to protect the pregnant woman’s developing fetus. Brachytherapy is internally placed radioactive material to treat clients who are affected with tumor and cancer of the prostate, lungs, esophagus, cervix, endometrium, rectum, breast, head and neck.
Special radiation precautions are initiated when a client is receiving brachytherapy in order to protect visitors and health care staff from the harmful effects of the radiation. Some of the other special internal radiation precautions include:
The minimization of the duration of time that health care providers are in the client’s room to deliver care and services to the client The placement of the client receiving internal radiation in a private room. A negative pressure room is not indicated for this client.
The prohibition of the client’s activities outside of their room
The initiation of complete bed rest for the client until the treatment is discontinued
The provision of education to the family members and other visitors that includes information about their need to limit the time of their visits to at least less than 1 hour, to stay at least 6 feet away from the client
The need for health care staff to minimize the amount of time spent in the room, to decline to enter the room if they are pregnant, to retain all supplies and equipment including things like bed linens in the client’s room until they are deemed safe for disposal by a person who is competent to make this decision, and how and when to report concerns about the client’s treatment such as when implanted seeds inadvertently leave the client’s body.
2. Which of the following is an adverse effect to therapeutic radiation therapy?
A.Fibrosis
B.Alopecia
C.Oral dryness
D.Xerostomia
Correct Response: A
Fibrosis is an adverse effect to therapeutic radiation therapy.
Radiation fibrosis can affect bones, nerves, ligaments, muscles, blood vessels, tendons, and the heart in addition to the lungs. Fibrosis occurs as the result of abnormal fibrin and protein accumulation within normal irradiated tissue.
Alopecia, and oral dryness which is also referred to as xerostomia, are side effects and complications to radiation, but not adverse effects.
Other side effects, complications and adverse effects associated with therapeutic radiation therapy are:
Skin damage
AND ANSWERS WITH
RATIONALES 2023
Physiological Integrity: Physiological Adaptation Questions
1. Your client is receiving brachytherapy. What nursing intervention should you implement for this client?
A.Exclude pregnant visitors from the client’s room.
B.Place the client in a negative pressure room.
C.Have all visitors wear protective masks and boots.
D.All of the above
Correct Response: A
You would exclude all pregnant visitors from the client’s room in order to protect the pregnant woman’s developing fetus. Brachytherapy is internally placed radioactive material to treat clients who are affected with tumor and cancer of the prostate, lungs, esophagus, cervix, endometrium, rectum, breast, head and neck.
Special radiation precautions are initiated when a client is receiving brachytherapy in order to protect visitors and health care staff from the harmful effects of the radiation. Some of the other special internal radiation precautions include:
The minimization of the duration of time that health care providers are in the client’s room to deliver care and services to the client The placement of the client receiving internal radiation in a private room. A negative pressure room is not indicated for this client.
The prohibition of the client’s activities outside of their room
The initiation of complete bed rest for the client until the treatment is discontinued
The provision of education to the family members and other visitors that includes information about their need to limit the time of their visits to at least less than 1 hour, to stay at least 6 feet away from the client
The need for health care staff to minimize the amount of time spent in the room, to decline to enter the room if they are pregnant, to retain all supplies and equipment including things like bed linens in the client’s room until they are deemed safe for disposal by a person who is competent to make this decision, and how and when to report concerns about the client’s treatment such as when implanted seeds inadvertently leave the client’s body.
2. Which of the following is an adverse effect to therapeutic radiation therapy?
A.Fibrosis
B.Alopecia
C.Oral dryness
D.Xerostomia
Correct Response: A
Fibrosis is an adverse effect to therapeutic radiation therapy.
Radiation fibrosis can affect bones, nerves, ligaments, muscles, blood vessels, tendons, and the heart in addition to the lungs. Fibrosis occurs as the result of abnormal fibrin and protein accumulation within normal irradiated tissue.
Alopecia, and oral dryness which is also referred to as xerostomia, are side effects and complications to radiation, but not adverse effects.
Other side effects, complications and adverse effects associated with therapeutic radiation therapy are:
Skin damage
