A nurse is caring for a client who is to start chemotherapy treatment advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?
I agree. Sometimes the adverse effect can be worse than the disease
"Someone from the American Cancer Society will be here soon to answer your questions
What is it about the adverse effects that concern you?
I will have your provider discuss the adverse effects with you before the treatment begins
The Correct Answer is C
A) "I agree. Sometimes the adverse effects can be worse than the disease":
While it's important for the nurse to acknowledge the client's concerns, making this statement may not be helpful in this situation. It could unintentionally reinforce fear and anxiety, implying that the chemotherapy's side effects may be worse than the disease itself, which is not always the case. Instead, the nurse should engage the client in a discussion to explore the specific concerns, allowing for tailored support and information.
B) "Someone from the American Cancer Society will be here soon to answer your questions":
While the American Cancer Society can provide valuable support and resources, referring the client to someone else to answer their questions can feel dismissive. The nurse should take the opportunity to listen to the client’s concerns and provide immediate reassurance or information. Direct involvement in the discussion builds trust and allows for more immediate emotional and psychological support.
C) "What is it about the adverse effects that concern you?":
This response is the most appropriate as it encourages the client to express their specific concerns. By asking the client to clarify their worries, the nurse can provide more accurate information, address misunderstandings, and offer reassurance. This open-ended question helps the nurse understand the client's emotions and individual needs, which allows for a more personalized approach in managing anxiety and providing education about the chemotherapy treatment.
D) "I will have your provider discuss the adverse effects with you before the treatment begins":
While it is important for the healthcare provider to discuss the treatment plan and potential side effects, the nurse should not defer the conversation entirely. The nurse plays an essential role in providing ongoing support, educating the client, and answering questions. The nurse can start the conversation and provide information about the common side effects of chemotherapy, offering the opportunity for further discussion with the provider as needed. Deferring the conversation might leave the client feeling unsupported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["13.7"]
Explanation
Given:
Ordered dose of Furosemide: 1 mg/kg
Patient weight: 121 lbs
Concentration of Furosemide: 40 mg/10 mL (4 mg/mL)
Step 1: Convert patient weight from pounds to kilograms:
1 pound (lb) = 0.453592 kilograms (kg)
Patient weight in kg = 121 lbs x 0.453592 kg/lb = 54.877832 kg
Step 2: Calculate the total dose of Furosemide:
Total dose (mg) = Ordered dose (mg/kg) x Patient weight (kg)
Total dose (mg) = 1 mg/kg x 54.877832 kg
Total dose (mg) = 54.877832 mg
Step 3: Calculate the volume to be administered:
Volume (mL) = Total dose (mg) / Concentration (mg/mL)
Volume (mL) = 54.877832 mg / 4 mg/mL
Volume (mL) = 13.719458 mL
Step 4: Round to the nearest tenth:
Volume (mL) ≈ 13.7 mL
Correct Answer is A
Explanation
A) Assess lung sounds and respiratory rate at least every 2 hours:
In a patient with Myasthenia Gravis (MG) who has undergone thymectomy, monitoring respiratory status is critical. MG is a neuromuscular disorder that can lead to respiratory muscle weakness, which may be exacerbated post-operatively. Assessing lung sounds and respiratory rate at least every 2 hours is crucial to detect early signs of respiratory compromise, including hypoventilation or atelectasis.
B) Assess and document pain level once every shift:
While pain assessment is important, especially after a thymectomy, this action alone does not directly address the immediate issue of ineffective breathing patterns. In patients with MG, respiratory complications are a priority concern. Pain management should be part of the overall plan of care, but it is secondary to monitoring respiratory function in the acute post-operative period. Pain can affect respiratory effort, but it should be managed in the context of more pressing issues like airway and breathing assessment.
C) Maintain sequential compression device (SCD's) while in bed:
While SCDs are important in preventing deep vein thrombosis (DVT) in patients who are immobile, they are not the most appropriate intervention for a client with ineffective breathing patterns. The primary concern in a post-thymectomy patient with MG is respiratory function.
D) Elevate the head of the bed ten degrees:
While elevating the head of the bed can help with comfort and potentially improve ventilation in some patients, it is not the most specific or effective intervention for managing ineffective breathing patterns in a patient with MG. For optimal respiratory function, it is typically more beneficial to elevate the head of the bed to a higher degree (e.g., 30-45 degrees) to enhance lung expansion, rather than just 10 degrees.
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