Nokea
The nurse is talking with a client who has breast cancer and is receiving tamoxifen. Which of the following statements by the client would require immediate follow-up?
- A. I have been experiencing frequent hot flashes
- B. I have been experiencing vaginal dryness
- C. I have had a decreased interest in sexual intercourse
- D. I have noticed that my menses are heavy
Correct Answer: D
Rationale: Heavy menses while on tamoxifen may indicate endometrial hyperplasia or cancer, a serious side effect requiring immediate evaluation. Hot flashes, vaginal dryness, and decreased libido are common, less urgent side effects.
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A laboring woman has been pushing for one hour and is not making progress. The nurse knows that which of the following could hinder the descent of the fetus in the second stage of labor?
- A. A full bladder
- B. Paracervical block given during the first stage of labor
- C. Mother placed in a side-lying position
- D. Fetus in LOA (left occiput anterior) position
Correct Answer: A
Rationale: A full bladder obstructs fetal descent by occupying pelvic space, hindering labor progress, unlike anesthesia, positioning, or optimal fetal position.
Following visitation, the nurse observes a client's wife sitting alone crying. When approached, the wife states, 'I'm so worried about him.' The best response by the nurse is:
- A. Are you worried about him being in the hospital?'
- B. Tell me what is worrying you.'
- C. Would you like to talk with the social worker assigned to your husband?'
- D. Would you like to talk with your husband's doctor?'
Correct Answer: B
Rationale: Tell me what is worrying you' encourages the wife to express her concerns, facilitating support. Other responses assume causes or defer to others prematurely.
The nurse has reinforced teaching with the parent of a 4-month-old with gastroesophageal reflux. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I will feed my baby smaller amounts more frequently
- B. I will place my baby in a side-lying position at night for sleep
- C. I will dilute my baby’s formula with water to decrease regurgitation
- D. I should massage my baby’s belly as soon as each feeding is complete
- E. I should hold my baby in an upright position for 20 to 30 minutes after each feeding
Correct Answer: A,E
Rationale: Smaller, frequent feedings and upright positioning reduce reflux. Side-lying is unsafe for sleep, diluting formula risks malnutrition, and massaging the belly post-feeding may increase regurgitation.
A client involved in a motor vehicle accident has a 4-inch laceration on her left lower leg. Which finding is consistent with an acute inflammatory reaction?
- A. Increased pain caused by the release of histamine
- B. Blanching of the skin proximal to the laceration
- C. A decrease in the white blood count
- D. Granulation of tissue at the edges of the laceration
Correct Answer: A
Rationale: Histamine release during acute inflammation causes pain and vasodilation. Blanching is not typical, white blood count increases, and granulation occurs later.
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
- A. Transparent film dressing
- B. Wet dressing with debridement granules
- C. Wet to dry with hydrogen peroxide
- D. Moist saline dressing
Correct Answer: D
Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.