Nokea
When supporting the psychosocial needs of a client experiencing negative side effects associated with chemotherapy, which intervention is most appropriate?
- A. Read the client's discharge instructions well in advance of dismissal
- B. Provide medications to reduce nausea and vomiting
- C. Give simple instructions about self-care while in the hospital
- D. Determine the levels of support from significant others
Correct Answer: D
Rationale: When a client is experiencing negative side effects associated with chemotherapy, addressing their psychosocial needs is crucial. One effective intervention is to determine the levels of support from significant others. This involves assessing the family, spouse, or friends who can provide help and support to the client when healthcare providers are not present. By identifying and organizing these resources, the nurse can help alleviate fears about the future, prepare caregivers for the client's needs, and facilitate a smoother transition for the client upon discharge. Reading discharge instructions, providing medications, or giving self-care instructions, although important, do not directly address the psychosocial needs of the client during this challenging time.
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When assessing a child admitted to the hospital with pyloric stenosis, which symptom would the nurse likely find when asking the parent about the child's symptoms?
- A. Watery diarrhea
- B. Projectile vomiting
- C. Increased urine output
- D. Vomiting large amounts of bile
Correct Answer: B
Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. The hallmark symptom of pyloric stenosis is projectile vomiting, which is the forceful expulsion of stomach contents. Other common symptoms include irritability, hunger and crying, constipation, and signs of dehydration. Watery diarrhea (Choice A) is not a typical symptom of pyloric stenosis. Increased urine output (Choice C) is not directly associated with this condition. Vomiting large amounts of bile (Choice D) is not a characteristic symptom of pyloric stenosis; instead, the vomitus in pyloric stenosis is non-bilious.
A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?
- A. Oculogyric crisis
- B. Tardive dyskinesia
- C. Nystagmus
- D. Dysphagia
Correct Answer: A
Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (Choice B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (Choice C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (Choice D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?
- A. Diarrhea
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Hyperactive bowel sounds
Correct Answer: C
Rationale: In the scenario of persistent vomiting, the child is at risk of developing metabolic alkalosis due to the loss of hydrochloric acid. Vomiting leads to the loss of gastric acid, resulting in an imbalance that causes metabolic alkalosis. Metabolic acidosis is incorrect as it would occur in a child with diarrhea due to the loss of bicarbonate. While diarrhea can sometimes be associated with vomiting, in this case, the primary focus is on the effects of vomiting. Hyperactive bowel sounds are not typically associated with vomiting, making this choice less relevant to the situation described.
After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?
- A. Elevate the buttocks.
- B. Document the findings.
- C. Apply ice immediately.
- D. Call the primary health care provider.
Correct Answer: B
Rationale: A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown. Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.
A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: It is essential for the nurse to guide the client on the initial steps in involving her 2 and 12-year-old sons in the care of their newborn sister. The most appropriate response is to 'Focus on your sons' needs during the first days at home.' In an expanded family, parents should prioritize reassuring older children that they are loved and as important as the newborn. This response acknowledges the importance of ensuring the well-being and emotional adjustment of the older siblings during the transition period. Choices B, C, and D are less appropriate as they do not directly address the emotional needs and adjustment of the older children during this significant family change.