Nokea
Cyclophosphamide is prescribed for the client diagnosed with breast cancer, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates the need for further teaching?
- A. If I lose my hair, it will grow back.
- B. If I develop a sore throat, I should notify the doctor.
- C. I need to limit my fluid intake while taking this medication.
- D. I need to avoid contact with anyone who recently received a live virus vaccine.
Correct Answer: C
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, requiring copious fluid intake (2–3 liters/day) to prevent it, not fluid restriction. Hair regrowth, reporting sore throat (indicating infection), and avoiding live virus vaccine contacts are correct due to immunosuppression.
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The nurse is planning discharge teaching for the parents of a child who sustained a head injury and who is now receiving tapering doses of dexamethasone. The nurse plans to make which statement to the parents?
- A. This medication decreases the chance of infection.
- B. This medication will be discontinued after two doses.
- C. If your child's face becomes puffy, the medication dose needs to be increased.
- D. This medication is tapered to decrease the chance of recurring swelling in the brain.
Correct Answer: D
Rationale: Dexamethasone sodium phosphate is a corticosteroid. The rebounding of cerebral edema is a side effect of dexamethasone sodium phosphate withdrawal if it is done abruptly. This medication decreases inflammation rather than infection. Facial edema is a common side effect that disappears when the medication is discontinued.
When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem?
- A. Avoid caffeine in your diet.
- B. Take your temperature every day.
- C. Limit your fluid intake to 1000 mL per 24 hours.
- D. Catheterize yourself every 2 hours as needed to prevent spasm.
Correct Answer: A
Rationale: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.
The nurse provides instructions regarding home care to a parent of a 3-year-old child who has been hospitalized with hemophilia. Which statement by the parent indicates the need for further teaching?
- A. I should not leave my child unattended.
- B. I need to pad table corners in my home.
- C. My child should not have any immunizations.
- D. I need to remove household items that can tip over.
Correct Answer: C
Rationale: Immunizations are important for children with hemophilia to prevent infections, and the parent's statement about avoiding them indicates a misunderstanding. Not leaving the child unattended, padding table corners, and removing tippable items are appropriate safety measures to prevent bleeding injuries.
Which factors increase the risk for hypothermia in an older client? Select all that apply.
- A. Burns
- B. Anemia
- C. Alcohol abuse
- D. Hypoglycemia
- E. Hyperthyroidism
- F. Poor thermoregulation
Correct Answer: A,B,C,D,F
Rationale: The median oral temperature of an older client is 96.8^{\circF}\left(36^{\circC}\right) . Environmental temperatures below 65^{\circF}\left(18^{\circC}\right) may cause a serious drop in core body temperature to 95^{\circF}\left(35^{\circC}\right) or less in the older client. Numerous factors increase the risk of hypothermia in the older client, including conditions that increase heat loss (e.g., burns); conditions that decrease heat production such as hypothyroidism, hypoglycemia, or anemia; medications or substances that interfere with thermoregulation, such as alcohol; or thermoregulatory impairment (failure to sense cold).
The nurse is teaching a newly diagnosed client about Crohn's disease. The nurse understands which barriers may prevent effective client learning? Select all that apply.
- A. language barriers
- B. motivation to learn
- C. lack of a support system
- D. adequate financial resources
- E. cognitive dysfunction, such as schizophrenia
Correct Answer: A,B,C,E
Rationale: Language barriers, low motivation, lack of support, and cognitive dysfunction hinder learning. Adequate finances are not a barrier.