Nokea
The client tells the nurse that since his diagnosis of stomach cancer, he has been having trouble sleeping and is frequently preoccupied with thoughts about how his life will change. He says, 'I wish my life could stay the same.' Based on this information, which one of the following nursing diagnoses would be appropriate at this time?
- A. Ineffective coping related to the diagnosis of cancer.
- B. Insomnia related to fear of the unknown.
- C. Grieving related to the diagnosis of cancer.
- D. Anxiety related to the need for gastric surgery.
Correct Answer: C
Rationale: The client's statement and symptoms suggest grieving related to the life-altering diagnosis of stomach cancer. This diagnosis best captures the emotional response to the anticipated changes.
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A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?
- A. Notify the attending physician and blood bank.
- B. Complete the appropriate Transfusion Reaction Form(s).
- C. Stop the transfusion.
- D. Keep the I.V. open with normal saline infusion.
Correct Answer: C,D,A,B
Rationale: In a transfusion reaction, the nurse must first stop the transfusion to prevent further infusion of the offending blood. Next, keep the IV line open with normal saline to maintain access and support circulation. Then, notify the physician and blood bank for further evaluation and management. Finally, complete the transfusion reaction forms to document the incident.
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first:
- A. Ask what medications the client is taking.
- B. Complete a history and health assessment.
- C. Identify the time of onset of the stroke.
- D. Determine if the client is scheduled for any surgical procedures.
Correct Answer: C
Rationale: The time of stroke onset is critical for t-PA administration, as it must be given within a specific window (typically 3-4.5 hours) to be effective and safe. Other assessments follow this priority.
While the nurse is providing preoperative teaching, the client says, 'I hate the idea of being an invalid after they cut off my leg.' The nurse's most therapeutic response should be:
- A. You'll still have one good leg to use.'
- B. Tell me more about how you're feeling.'
- C. Let's finish the preoperative teaching.'
- D. You're fortunate to have a wife who can take care of you.'
Correct Answer: B
Rationale: The therapeutic response, 'Tell me more about how you're feeling,' encourages the client to express fears and concerns, facilitating emotional support and coping. The other responses dismiss the client's feelings, prioritize teaching, or make assumptions, which are less therapeutic.
Crackles heard on lung auscultation indicate which of the following?
- A. Cyanosis.
- B. Bronchospasm.
- C. Airway narrowing.
- D. Fluid-filled alveoli.
Correct Answer: D
Rationale: Crackles indicate fluid in the alveoli, often due to pulmonary edema in heart failure or post-MI, reflecting left ventricular dysfunction.
Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects?
- A. Retinopathy.
- B. Constipation.
- C. Flulike symptoms.
- D. Hypoglycemia.
Correct Answer: C
Rationale: Interferon alfa-2b commonly causes flulike symptoms (C), such as fever, chills, and fatigue, which are expected adverse effects. Retinopathy (A), constipation (B), and hypoglycemia (D) are not typically associated with this medication.