Nokea
The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?
- A. That is not an easy choice to make. I will notify your health care provider of your decision
- B. Have you considered how this decision might affect your spouse and children?
- C. I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life
- D. Have you discussed this decision with someone else that you trust?
Correct Answer: A
Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.
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While caring for a child with Reye's syndrome, the nurse should give which action the highest priority?
- A. Monitor intake and output
- B. Provide good skin care
- C. Assess level of consciousness
- D. Assist with range of motion
Correct Answer: C
Rationale: Assess level of consciousness. An altered level of consciousness suggests increasing intracranial pressure related to cerebral edema.
The nurse is caring for a newborn who has a cleft palate. Which of the following actions should the nurse take to promote oral intake? Select all that apply.
- A. Use specialty bottles or nipples
- B. Burp the newborn often when feeding
- C. Feed the newborn in an upright position
- D. Initiate feeding as soon as possible after birth
- E. Encourage the mother to exclusively breastfeed
Correct Answer: A,B,C
Rationale: Specialty bottles, frequent burping, and upright positioning facilitate feeding and reduce aspiration risk in cleft palate. Early feeding is appropriate but not specific, and exclusive breastfeeding is often challenging.
The nurse is reinforcing teaching with a client who has a prescription for sertraline for the treatment of depression. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I can discontinue the medication as soon as I start feeling better
- B. I should avoid eating aged cheeses, cured meats, or pickled foods
- C. I should expect to feel better within 2 to 3 days after starting this medication
- D. I will report any thoughts of self-harm to my health care provider
Correct Answer: D
Rationale: Reporting self-harm thoughts is critical, as sertraline may increase suicide risk initially. Discontinuing abruptly risks relapse, food restrictions apply to MAOIs, and benefits take weeks, not days.
The nurse reinforces teaching for a client taking atorvastatin to call the health care provider if experiencing which symptom associated with a serious adverse effect of the medication?
- A. Diarrhea
- B. Headache
- C. Muscle aches
- D. Numbness in the feet
Correct Answer: C
Rationale: Muscle aches may indicate myopathy or rhabdomyolysis, serious atorvastatin side effects requiring immediate attention. Diarrhea, headaches, and numbness are less specific or unrelated.
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.