Nokea
The client who had a right modified radical mastectomy four (4) years before is being admitted for a cardiac work-up for chest pain. Which intervention is most important for the nurse to implement?
- A. Determine when the client had chemotherapy last.
- B. Ask the client if she received Adriamycin, an antineoplastic agent.
- C. Post a message at the HOB for staff not to use the right arm for venipunctures or BPs.
- D. Examine the chest wall for cancer sites.
Correct Answer: C
Rationale: Post-mastectomy, the affected arm is at risk for lymphedema; avoiding venipuncture or BP on that arm is critical. Chemotherapy history is less urgent, Adriamycin relates to cardiotoxicity but not immediate care, and chest wall exam is secondary.
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The 80-year-old male client has been diagnosed with cancer of the prostate. Which treatment should the nurse discuss with the client?
- A. Radiation therapy every day for four (4) weeks.
- B. Radical prostatectomy with lymph node dissection.
- C. Diethylstilbestrol (DES), an estrogen, daily.
- D. Penile implants to maintain sexual functioning.
Correct Answer: A
Rationale: Radiation therapy is often preferred for elderly patients with prostate cancer, balancing efficacy and lower surgical risk. Prostatectomy is invasive, DES is rarely used, and penile implants are unrelated.
On the basis of this client's age, which statement by the nurse is the best explanation for the client's discomfort?
- A. The pelvic muscles are more sensitive to pressure after menopause.
- B. The clitoris is unable to respond to sexual foreplay as women age.
- C. The vagina hypertrophies if intercourse is infrequent.
- D. The mucus-producing glands decrease with aging.
Correct Answer: D
Rationale: Postmenopausal vaginal dryness due to decreased mucus production is a common cause of painful intercourse in older women.
While assessing a male client with tertiary syphilis, which finding is most characteristic of this stage of the disease?
- A. Stabbing leg pain
- B. Red, raised rash
- C. Fever
- D. Patchy hair loss
Correct Answer: A
Rationale: Tertiary syphilis can cause neurological symptoms like tabes dorsalis, characterized by stabbing leg pain due to nerve damage.
The client is diagnosed with benign uterine fibroid tumors. Which question should the nurse ask to determine if the client is experiencing a complication?
- A. How many periods have you missed?'
- B. Do you get short of breath easily?'
- C. How many times have you been pregnant?'
- D. Where is the location of the pain you are having?'
Correct Answer: D
Rationale: Pain location helps identify complications like fibroid degeneration or pressure on organs. Missed periods are common, shortness of breath is unrelated, and pregnancy history is less relevant.
The client has failed to conceive after many attempts over a three (3)-year time period and asks the nurse, 'I have tried everything. What should I do now?' Which statement is the nurse’s best response?
- A. By “everything” do you mean you have consulted an infertility specialist?'
- B. You have tried everything. This must be hard for you. Would you like to talk?'
- C. You should get on an adoption list because it can take a long time.'
- D. You need to relax and not try so hard. It is your nerves preventing conception.'
Correct Answer: A
Rationale: Referring to an infertility specialist is proactive, addressing potential medical causes. Emotional support is secondary, adoption is premature, and blaming nerves is unhelpful.