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A client with a diagnosis of breast cancer is prescribed exemestane (Aromasin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of exemestane requiring immediate reporting.
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The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following interventions should be included in the plan of care?
- A. Encourage early ambulation.
- B. Apply cold compresses to the affected leg.
- C. Elevate the affected leg.
- D. Massage the affected leg.
Correct Answer: A, C
Rationale: Early ambulation and leg elevation promote venous return and prevent clot progression. Cold compresses and massage are contraindicated.
The nurse instructs a female client about collecting a midstream urine sample for culture and sensitivity. Which should the nurse include in client teaching?
- A. Bathe before collecting the specimen.
- B. Cleanse the perineum from front to back.
- C. Label specimen with the provider's name.
- D. Collect urine at the beginning of urination.
Correct Answer: B
Rationale: To prepare properly for collection of a sterile urine specimen, the client cleanses the perineum from front to back using antiseptic swabs. Bathing before a midstream urine collection is unnecessary; however, proper specimen handling is critically important because improper specimen handling can yield inaccurate test results. The specimen should be labeled with the client's name, date, time, and medical record number in addition to the provider's name. The client should begin the flow of urine and collect the sample after starting the flow of urine, and then send the specimen to the laboratory as soon as possible.
A client with a history of depression is prescribed fluoxetine (Prozac). The nurse should instruct the client to report which of the following side effects?
- A. Insomnia.
- B. Bradycardia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Fluoxetine commonly causes insomnia, which should be reported to manage treatment.
To maintain a safe milieu while addressing the needs of the cognitively impaired clients on the unit, which interventions should the psychiatric nurse implement? Select all that apply.
- A. Use distracting techniques when appropriate.
- B. Be consistently visible and available to the clients.
- C. Provide reality orientation to the clients as needed.
- D. Anticipate the needs of the clients as much as possible.
- E. Segregate potentially volatile clients from the other clients.
Correct Answer: A,B,C,D
Rationale: To maintain a safe milieu for cognitively impaired clients, the nurse should use distracting techniques to redirect inappropriate behaviors, be consistently visible and available to provide reassurance and support, provide reality orientation to help clients maintain awareness of their surroundings, and anticipate client needs to prevent distress or agitation. Segregating potentially volatile clients is not typically recommended as it may increase feelings of isolation or stigmatization; instead, managing their behavior through de-escalation and individualized care is preferred.
A client tells the nurse, 'Everybody smiles at me because they know that I was chosen by God for this mission.' The nurse interprets this statement as which of the following?
- A. Idea of reference.
- B. Thought insertion.
- C. Visual hallucination.
- D. Neologism.
Correct Answer: A
Rationale: The statement reflects an idea of reference, where the client believes others' actions (smiling) are related to their special mission, a common delusion in psychiatric conditions.