Nokea
The nurse is talking with a client who has breast cancer and is receiving tamoxifen. Which of the following statements by the client would require immediate follow-up?
- A. I have been experiencing frequent hot flashes
- B. I have been experiencing vaginal dryness
- C. I have had a decreased interest in sexual intercourse
- D. I have noticed that my menses are heavy
Correct Answer: D
Rationale: Heavy menses while on tamoxifen may indicate endometrial hyperplasia or cancer, a serious side effect requiring immediate evaluation. Hot flashes, vaginal dryness, and decreased libido are common, less urgent side effects.
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The nurse has reinforced teaching with a client who has gout. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Drink plenty of fluids, including at least 2 L of water daily
- B. Reduce your consumption of alcohol or abstain from drinking
- C. Take aspirin instead of acetaminophen for minor pain or discomfort
- D. Implement a diet and physical activity regimen to maintain a healthy weight
- E. Select protein sources that are low in purine, such as low-fat dairy products
Correct Answer: A,B,D,E
Rationale: Fluids, reduced alcohol, weight management, and low-purine proteins reduce uric acid and gout flares. Aspirin can increase uric acid levels, worsening gout, and should be avoided.
The nurse is reviewing the medication profile for a client with chronic obstructive pulmonary disease. Which prescription should the nurse question?
- A. Amlodipine
- B. Codeine
- C. Ipratropium
- D. Methylprednisolone
Correct Answer: B
Rationale: Codeine, an opioid, suppresses cough and respiration, risking respiratory depression in COPD. Amlodipine treats hypertension, ipratropium relieves bronchospasm, and methylprednisolone reduces inflammation, all appropriate for COPD.
Following visitation, the nurse observes a client's wife sitting alone crying. When approached, the wife states, 'I'm so worried about him.' The best response by the nurse is:
- A. Are you worried about him being in the hospital?'
- B. Tell me what is worrying you.'
- C. Would you like to talk with the social worker assigned to your husband?'
- D. Would you like to talk with your husband's doctor?'
Correct Answer: B
Rationale: Tell me what is worrying you' encourages the wife to express her concerns, facilitating support. Other responses assume causes or defer to others prematurely.
The nurse is caring for a client who was admitted for treatment of schizoaffective disorder with visual hallucinations. He tells the nurse that he sees extraterrestrials that are coming to get him. What is the best nursing response?
- A. You know that extraterrestrials are make-believe.'
- B. Call his physician and report this visual hallucination.
- C. Ignore his comment and change the subject.
- D. You think someone is coming after you?'
Correct Answer: D
Rationale: Reflecting the client's statement validates his experience without reinforcing the hallucination, promoting therapeutic communication.
The nurse is talking with a client recently diagnosed with HIV infection about home and lifestyle alterations. Which of the following statements indicate that the client correctly understands the teaching? Select all that apply.
- A. I should avoid eating raw or undercooked meats and eggs to prevent infections
- B. I need to make sure my family members understand not to borrow my shaving razors
- C. I do not need to use barrier methods of protection if my sexual partner is also HIV positive
- D. I have started to use latex-free condoms during sexual intercourse because I have a latex allergy
Correct Answer: A,B,D
Rationale: Avoiding raw foods, not sharing razors, and using latex-free condoms reduce infection and transmission risks. Barrier methods are still needed with HIV-positive partners to prevent superinfection.