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A client who is diagnosed with breast cancer asks the nurse, 'Am I going to die?' Which statement by the nurse promotes a therapeutic relationship?
- A. Cancer is no longer a death sentence; you may live for many years.
- B. I will ask the chaplain to come and talk to you sometime today.
- C. Many people with cancer experience fear of dying; tell me about your concerns.
- D. Tell me about your life. What are your hopes and goals for the future?
Correct Answer: C
Rationale: This response validates the client's fear and invites further discussion, fostering trust and a therapeutic relationship. A offers reassurance but may dismiss the client's emotions. B deflects to another provider without addressing the concern. D shifts focus away from the client's immediate fear, missing the opportunity to explore their feelings.
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A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection. The nurse reminds the client to observe for and notify the health care provider immediately about which of the following?
- A. Brown-colored urine
- B. Hearing and balance problems
- C. Pain in the Achilles tendon area
- D. Sunburn
Correct Answer: C
Rationale: Ciprofloxacin is associated with Achilles tendon rupture, a serious side effect requiring immediate reporting. Other symptoms are less specific.
A mother telephones the clinic and says 'I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding.' The nurse's best response would be which of these?
- A. This type of stool is normal for breast fed infants. Keep doing as you have.'
- B. The stool should have turned to light brown by now. We need to test the stool.'
- C. Formula supplements might need to be added to increase the bulk of the stools.'
- D. Water should be offered several times each day in addition to the breast feeding.'
Correct Answer: A
Rationale: In breast-fed infants, stools are frequent and yellow to golden, and vary from soft to thick liquid in consistency. No change in feedings is indicated.
Which of the following laboratory values requires immediate follow-up?
- A. phenytoin level of 8 mcg/mL (32 mcmol/L) for a client who is receiving enteral feedings
- B. digoxin level of 1.3 ng/mL (1.7 nmol/L) for a client who has a heart rate of 62/min
- C. lithium level of 0.8 mEq/L (0.8 mmol/L) for a client who is reporting a decreased appetite
- D. International normalized ratio (INR) of 3 for a client who has a prosthetic aortic valve
Correct Answer: A
Rationale: Phenytoin levels of 8 mcg/mL are subtherapeutic (therapeutic range: 10-20 mcg/mL), especially with enteral feedings that reduce absorption, requiring immediate adjustment.
The nurse is screening clients for those at risk of developing syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should recognize that the client at highest risk for developing SIADH is a client with
- A. carpal tunnel syndrome
- B. small cell lung cancer
- C. osteomyelitis
- D. sciatica
Correct Answer: B
Rationale: Small cell lung cancer is strongly associated with SIADH due to ectopic ADH production. Other conditions listed are not significant risk factors.
A client with seizure disorder has an order for Dilantin (Phenytoin). Which of the following is not a side effect of Dilantin (Phenytoin)?
- A. Gingival hypertrophy
- B. Insomnia
- C. Diarrhea
- D. Slurred speech
Correct Answer: B
Rationale: Dilantin causes gingival hypertrophy, slurred speech, and occasionally diarrhea, but insomnia is not a common side effect.