Nokea
A 45-year-old female client with breast cancer has completed chemotherapy and reports a decreased interest in sexual activity. The nurse should:
- A. Encourage her to discuss her feelings with her partner.
- B. Suggest she resume sexual activity to improve her mood.
- C. Refer her immediately to a sexual therapist.
- D. Advise her to wait until chemotherapy effects subside.
Correct Answer: A
Rationale: Encouraging open communication with her partner allows the client to address emotional and physical factors contributing to decreased sexual interest, fostering support and understanding.
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The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful outcome for this diagnosis?
- A. The client assists as much as possible in his care, demonstrating increased participation over time.
- B. The client allows the nurse to complete his care in an efficient manner without interfering.
- C. The client allows his wife to assume total responsibility for his care.
- D. The client allows his wife to complete his care to promote feelings of usefulness.
Correct Answer: A
Rationale: Increased participation in self-care indicates progress toward independence despite traction limitations.
The nurse should assess the client with bladder cancer for which of the following?
- A. Suprapubic pain.
- B. Dysuria.
- C. Painless hematuria.
- D. Urine retention.
Correct Answer: C
Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often presenting as the initial sign due to tumor growth causing bleeding without associated pain.
A nurse is obtaining consent for a bone marrow aspiration. What should the nurse do? Select all that apply.
- A. Witness the client signing the consent form.
- B. Evaluate that the client understands the procedure.
- C. Explain the risks of the procedure to the client.
- D. Verify that the client is signing the consent form of his own free will.
- E. Determine that the client understands postprocedure care.
Correct Answer: A,B,D,E
Rationale: The nurse's role in obtaining consent includes witnessing the signature, ensuring the client understands the procedure and postprocedure care, and verifying voluntary consent. Explaining risks is typically the physician's responsibility.
A postoperative client is prescribed enoxaparin (Lovenox) 40 mg subcutaneous daily. Which laboratory value should the nurse monitor?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Activated partial thromboplastin time (aPTT).
- D. International normalized ratio (INR).
Correct Answer: A
Rationale: Enoxaparin can cause thrombocytopenia. Monitoring platelet count ensures early detection of this potential adverse effect.
Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include:
- A. Reassuring the client that pain will be relieved.
- B. Documenting the client's response to pain medication on a routine basis.
- C. Instructing the client to continue pressing the system's button whenever pain occurs.
- D. Titrating the client's pain medication until the client is free from pain.
Correct Answer: B
Rationale: Documenting the client's response to PCA is a key nursing responsibility to monitor efficacy and safety. Reassuring complete relief, instructing to press repeatedly, or titrating to pain-free status may be unrealistic or unsafe.