Nokea
An adult is receiving cancer chemotherapy. Metoclopramide (Reglan) is also prescribed. The client asks why she is getting Reglan. How should the nurse respond?
- A. Reglan helps to prevent bleeding that may occur as a side effect of your other medications.'
- B. Reglan helps to prevent any nausea and vomiting that may occur as a side effect of your other medications.'
- C. Reglan increases the effectiveness of the cancer chemotherapeutic agents.'
- D. Reglan helps to control pain associated with your disease.'
Correct Answer: B
Rationale: Metoclopramide is an antiemetic, prescribed to prevent nausea and vomiting, common chemotherapy side effects, improving patient comfort.
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During report, the nurse is given all of the following information. Which client should the nurse go to first?
- A. A diabetic has a blood sugar of 200.
- B. A client who had abdominal surgery earlier today is complaining of operative site pain.
- C. A client who had abdominal surgery yesterday has crackles on auscultation.
- D. A client who had a thyroidectomy earlier today is complaining of muscle spasms.
Correct Answer: D
Rationale: Muscle spasms post-thyroidectomy suggest hypocalcemia from parathyroid injury, a potentially life-threatening emergency requiring immediate assessment. High glucose, pain, or crackles are less urgent.
A veteran is admitted with a diagnosis of chronic post-traumatic stress disorder. After being placed in the treatment room, he begins to pace frantically and make references to 'highway one.' As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tight to his body. The client is experiencing a:
- A. Hallucination
- B. Phobic reaction
- C. Delusion
- D. Flashback
Correct Answer: D
Rationale: The behavior and reference to 'highway one' suggest a flashback, where the client is reliving a traumatic event, common in PTSD.
What is the primary goal of family education?
- A. symptom reduction
- B. improved quality of life
- C. increased knowledge about mental illness
- D. improved caregiving skills
Correct Answer: B
Rationale: Improving quality of life is the primary goal of family education.
All of the following clients need attention. Which one should the nurse go to first?
- A. The nursing assistant reports that a client who had a T3 spinal cord transection several months ago has a severe headache and blurred vision.
- B. The nursing assistant needs help turning a client who had a CVA.
- C. The physician is about to examine a client who has multiple sclerosis and requests that the nurse be present.
- D. A client who has amyotrophic lateral sclerosis needs help with ambulating.
Correct Answer: A
Rationale: Severe headache and blurred vision in spinal cord injury suggest autonomic dysreflexia, a life-threatening emergency, prioritizing immediate attention over turning, examination, or ambulation.
What information would be most important for the nurse to obtain from a client with suspected bladder cancer who reports blood in the urine but no associated pain?
- A. Family history
- B. Industrial chemical exposure
- C. Tobacco use
- D. Usual diet
Correct Answer: C
Rationale: Tobacco use is the strongest risk factor for bladder cancer, strongly linked to painless hematuria. Chemical exposure is relevant but less common, family history is weak, and diet is not a primary factor.