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A nurse is caring for a client with lung cancer who develops syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory finding should the nurse expect?
- A. Serum sodium of 128 mEq/L.
- B. Serum potassium of 5.5 mEq/L.
- C. Serum calcium of 11.0 mg/dL.
- D. Serum glucose of 200 mg/dL.
Correct Answer: A
Rationale: SIADH causes water retention, diluting serum sodium, so a low sodium level (128 mEq/L) is expected due to the inappropriate secretion of antidiuretic hormone.
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The nurse is caring for a client diagnosed with Reye's syndrome. The nurse understands that this illness is caused by which medication?
- A. Ibuprofen
- B. Aspirin
- C. Acetaminophen
- D. Diphenhydramine
Correct Answer: B
Rationale: Reye's syndrome is associated with aspirin use, particularly in children with viral infections, leading to liver and brain complications.
Essential hypertension would be diagnosed in a 40-year-old male whose blood pressure readings were consistently at or above which of the following?
- A. 120/90 mm Hg.
- B. 130/85 mm Hg.
- C. 140/90 mm Hg.
- D. 160/80 mm Hg.
Correct Answer: C
Rationale: Essential hypertension is diagnosed with consistent blood pressure readings at or above 140/90 mm Hg, per standard guidelines.
A 36-year-old female is scheduled to receive external radiation therapy and a cesium implant for cancer of the cervix. Which of the following statements would be most accurate to include in the teaching plan about the potential effects of radiation therapy on sexuality?
- A. You can have sexual intercourse while the implant is in place.
- B. You may notice some vaginal dryness after treatment is completed.
- C. You may notice some vaginal relaxation after treatment is completed.
- D. You will continue to have normal menstrual periods during treatment.
Correct Answer: B
Rationale: Vaginal dryness is a common side effect of cervical radiation due to mucosal changes, and should be included in the teaching plan to prepare the client.
The nurse teaches the client how to instill nose drops. Which of the following techniques is correct?
- A. The client uses sterile technique when handling the dropper.
- B. The client blows the nose gently before instilling drops.
- C. The client uses a new dropper for each instillation.
- D. The client sits in a semi-Fowler's position with the head tilted forward after administration of the drops.
Correct Answer: B
Rationale: Blowing the nose gently before instilling nose drops clears the nasal passages, allowing better medication absorption. Sterile technique is not typically required for home use. Using a new dropper each time is impractical. The head should be tilted back, not forward, after administration to allow the drops to spread.
A client with a recent amputation reports phantom limb pain. Which intervention should the nurse implement first?
- A. Administer prescribed gabapentin.
- B. Apply a cold pack to the stump.
- C. Distract the client with music.
- D. Explain the nature of phantom pain.
Correct Answer: D
Rationale: Explaining phantom pain validates the client's experience, addressing anxiety before other interventions.