Nokea
A client with metastatic esophageal cancer says, 'I don't want to be kept alive being fed by a tube.' What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.
- A. Document this communication in the electronic health record
- B. Encourage the client to discuss this decision with the health care proxy
- C. Facilitate completion of an advance directive that reflects the client's decision
- D. Obtain a signed informed consent from the client
- E. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order
Correct Answer: A, B, C
Rationale: Documenting in the EHR (A), discussing with the proxy (B), and completing an advance directive (C) ensure the client's wishes are communicated. Informed consent (D) is irrelevant, and DNR (E) is not indicated.
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The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?
- A. I've felt the need for an afternoon nap most days this week.'
- B. I've gained 3 lb (1.36 kg) since I began taking this medication.'
- C. I've had the stomach flu for the past couple of days.'
- D. My mouth seems to be drier than usual lately.'
Correct Answer: C
Rationale: Stomach flu (C) can cause dehydration, increasing lithium toxicity risk, requiring immediate concern. Naps (A), weight gain (B), and dry mouth (D) are less urgent side effects.
Which of the following clients does the nurse identify as being at high risk for developing colorectal cancer? Select all that apply.
- A. Client who has a diet high in red meat and low in fiber
- B. Client who is morbidly obese
- C. Client with a 15-year history of ulcerative colitis
- D. Client with a 40-year history of cigarette smoking
- E. Client with a family history of colorectal cancer
Correct Answer: A, C, E
Rationale: High red meat/low fiber diet (A), ulcerative colitis (C), and family history (E) are established risk factors for colorectal cancer. Obesity (B) and smoking (D) have weaker associations.
The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?
- A. Fecal impaction
- B. Infrequent voiding
- C. Stress incontinence
- D. Burning with urination
Correct Answer: A
Rationale: Fecal impaction. The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.
The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?
- A. Need for an eye examination
- B. Need for sunblock
- C. Risk for infection
- D. Risk for kidney injury
Correct Answer: C
Rationale: Methotrexate suppresses the immune system, significantly increasing the risk for infection (C). This is a critical teaching point to ensure the client takes precautions. Eye exams (A), sunblock (B), and kidney injury (D) are less directly associated with methotrexate's primary risks.
An adult is scheduled for a total laryngectomy. When preparing the client for surgery, it is essential for the nurse to take which of the following actions?
- A. Teach the client esophageal speech
- B. Teach the client how to lip read
- C. Assess the client's ability to read and write
- D. Determine the client's usual means of dealing with a sore throat
Correct Answer: C
Rationale: A laryngectomy removes the voice box, requiring alternative communication; assessing literacy ensures post-op communication via writing, critical for care planning.