Nokea
An adult who has multiple sclerosis is receiving cyclophosphamide (Cytoxan). The client asks the nurse why she is receiving the same drug her mother had when she had Hodgkin's disease. The nurse should include which information when responding?
- A. Multiple sclerosis is a type of cancer, so the same drugs are effective for both conditions.
- B. A side effect of cyclophosphamide (Cytoxan), a cancer drug, is immunosuppression. In multiple sclerosis, the immune system is attacking the client's nerves.
- C. Hodgkin's disease causes nervous system symptoms similar to those seen in multiple sclerosis.
- D. Multiple sclerosis and Hodgkin's disease are caused by the same organism, so the same drug is appropriate.
Correct Answer: B
Rationale: Cyclophosphamide's immunosuppressive effect reduces immune activity in MS, where the immune system attacks nerves, unlike cancer treatment, symptom similarity, or shared etiology.
You may also like to solve these questions
A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting.
- A. What is the best indication that the nutritional status of a woman with metastatic ovarian cancer has improved after 4 days of TPN?
- B. The patient eats most of the food served to her.
- C. The patient has gained 1 pound since admission.
- D. The patient’s albumin level is 0 mg/dL.
- E. The patient’s hemoglobin is 8.5 g/dL.
Correct Answer: C
Rationale: Albumin levels (normal 5–5.0 g/dL) are the best indicator of long-term nutritional status, reflecting protein stores. A level of 0 mg/dL indicates improved nutrition. Eating more, weight gain (which may be fluid), or hemoglobin levels (affected by cancer or chemotherapy) are less reliable indicators.
The nurse is caring for a client in the outpatient clinic who is four months pregnant.
- A. Which symptom reported by a four-month pregnant client requires immediate follow-up?
- B. Intermittent nausea in the morning.
- C. A white vaginal discharge.
- D. Breast tenderness bilaterally.
- E. Feeling the need to void more frequently.
Correct Answer: A
Rationale: Intermittent nausea in the second trimester (four months) is abnormal, as morning sickness typically resolves by the end of the first trimester, and may indicate complications like hyperemesis gravidarum or other issues requiring evaluation. Vaginal discharge, breast tenderness, and frequent urination are normal pregnancy symptoms.
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
- A. Stand on 1 foot
- B. Catch a ball
- C. Skip on alternate feet
- D. Ride a bicycle
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.
A client who is receiving a tube feeding around the clock.
Which of the following nursing actions is MOST appropriate?
- A. Rinse the bag and change the formula every four hours.
- B. Rinse the bag and change the formula every shift.
- C. Change the bag and formula every shift.
- D. Rinse the bag and change the formula every two hours.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-there is an increased growth of organisms after four hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis
The nurse is caring for a 17-year-old married male scheduled for a hernia repair. The nurse administers meperidine hydrochloride (Demerol) 50 mg and hydroxyzine pamoate (Vistaril) 25 mg IM. Thirty minutes later the nurse discovers that the informed consent is unsigned.
Which of the following actions by the nurse is BEST?
- A. Cancel the surgery.
- B. Ask the client to sign the informed consent.
- C. Notify the physician.
- D. Ask the client's mother to sign the informed consent.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate action, should inform physician (2) can't sign informed consent if client has been drinking alcohol or has been pre-medicated for surgery (3) correct-physician needs to be informed (4) married minor is considered emancipated; provides own consent for treatment