Nokea
A nurse is assessing a client with metastatic lung cancer. The nurse should assess the client for:
- A. Diarrhea.
- B. Constipation.
- C. Hoarseness.
- D. Weight gain.
Correct Answer: C
Rationale: Hoarseness is a common symptom of metastatic lung cancer due to tumor effects on the larynx or recurrent laryngeal nerve. Constipation, diarrhea, and weight gain are less specific.
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When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches?
- A. Questioning the client about how much alcohol she drinks.
- B. Confronting the client with the fact that she was intoxicated 2 days ago.
- C. Pointing out how alcohol has gotten her into trouble.
- D. Listening to what the client states and then asking her how she plans to stay sober.
Correct Answer: D
Rationale: This approach uses therapeutic communication, acknowledging the client's perspective and encouraging problem-solving, which is effective for addressing denial in alcohol dependency.
A client with a history of chronic lymphocytic leukemia is admitted with fatigue. The nurse should monitor the client for which of the following?
- A. Anemia.
- B. Hyperkalemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Chronic lymphocytic leukemia can cause anemia due to bone marrow suppression, leading to fatigue.
The nurse is caring for a client post-cataract surgery. Which instruction should the nurse include in discharge teaching?
- A. Avoid bending at the waist
- B. Resume driving immediately
- C. Wear glasses at all times
- D. Sleep on the operative side
Correct Answer: A
Rationale: Avoiding bending at the waist prevents increased intraocular pressure, which could complicate recovery post-cataract surgery.
A client complains of a dull headache and dizziness and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide,50 mm Hg; and bicarbonate, 24 mEq/L. These findings indicate which of the following acid-base imbalances?
- A. Respiratory alkalosis
- B. Respiratory acidosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: A pH of 7.26 (acidic) with elevated CO2 (50 mm Hg) and normal bicarbonate (24 mEq/L) indicates respiratory acidosis, likely due to hypoventilation. Other imbalances do not match these values.
The nurse is obtaining a health history for a client with osteoporosis. The nurse should specifically ask the client about which of the following? Select all that apply.
- A. Amount of alcohol consumed daily.
- B. Use of antacids.
- C. Dietary intake of fiber.
- D. Use of Vitamin K supplements.
- E. Intake of fruit juices.
Correct Answer: A, B
Rationale: Excessive alcohol consumption and frequent antacid use (which may contain aluminum, reducing calcium absorption) are risk factors for osteoporosis. Fiber, vitamin K, and fruit juices are less relevant.