A nurse is preparing a client who is to receive chemotherapy for the treatment of breast cancer. Which of the following actions should the nurse plan to take?

Have the client floss 4 times daily.

Have the client swish with commercial mouthwash before therapy.

Tell the client to expect dark stools following chemotherapy.

Administer an antiemetic prior to the procedure.

Answer and Explanation

The Correct Answer is D

Choice A reason : Having the client floss 4 times daily is not typically recommended during chemotherapy because their gums may be more prone to bleeding due to a decrease in platelets, which is a common side effect of chemotherapy¹. Instead, gentle oral care is advised to prevent damage to the oral mucosa.

Choice B reason : Having the client swish with commercial mouthwash before therapy is not generally recommended because many commercial mouthwashes contain alcohol, which can be irritating to the mucous membranes and may exacerbate chemotherapy-induced mucositis¹. Instead, a saline rinse or a prescribed mouthwash without alcohol may be used to help manage oral hygiene during chemotherapy.

Choice C reason : Telling the client to expect dark stools following chemotherapy could be misleading. While some chemotherapy drugs can cause changes in stool color, dark stools can also indicate gastrointestinal bleeding, which requires immediate medical attention¹. Therefore, patients should be instructed to report any significant changes in stool color to their healthcare provider.

Choice D reason : Administering an antiemetic prior to the procedure is a standard practice to prevent nausea and vomiting associated with chemotherapy¹. Antiemetics are medications that can help control these common side effects, improving the patient's comfort and ability to tolerate the treatment.

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Correct Answer is ["A","B","C"]

Explanation

Choice A reason : Answering questions with nonsensical phrases is a positive symptom of schizophrenia. It reflects disorganized thinking and speech, which can manifest as incoherence or irrelevance in the patient's verbal communication². This symptom can significantly impair the patient's ability to engage in meaningful conversation and is often one of the more noticeable signs of schizophrenia during an assessment³.

Choice B reason : Seeing, hearing, or feeling something that is not really there, also known as hallucinations, are hallmark positive symptoms of schizophrenia. These sensory experiences occur without an external stimulus and can involve any of the senses, although auditory hallucinations are the most common in schizophrenia². Hallucinations can be extremely distressing for patients and can lead to difficulties in distinguishing reality from delusion³.

Choice C reason : The belief that personal significance is attached to trivial or unrelated external events, known as delusions of reference, is another positive symptom of schizophrenia. Patients may believe that messages are being sent to them through the television, radio, or other public means². This can lead to a profound sense of misunderstanding and isolation as the patient navigates a world they perceive as filled with hidden messages meant specifically for them³.

Choice D reason : While trouble staying on a schedule or finishing tasks can be associated with schizophrenia, it is not considered a positive symptom. These issues are more reflective of the negative symptoms of schizophrenia, which include avolition or the lack of motivation to initiate and complete goal-directed activities⁴.

Choice E reason : An inability to socially connect with others is also not a positive symptom but rather a negative symptom of schizophrenia. Negative symptoms represent a loss or a decrease in the ability to initiate plans, speak, express emotion, or find pleasure in everyday life⁴. Social withdrawal and impaired social interaction are common negative symptoms that can be mistaken for introversion or depression³.

A. A 40-year-old woman who came into the ER with a swollen, painful calf and now complains of chest pains and having trouble breathing, with tachycardia and tachypnea. B. A 60-year-old man who is tired and has been in the med-surg unit for 3 days with AKI after taking IV antibiotics. C. A 30-year-old man with a history of smoking and a sedentary lifestyle who had an appendectomy 1 day ago and is refusing to ambulate or wear compression stockings. D. A 55-year-old woman who came into the ER with chest pains, shortness of breath, nausea, tachypnea, and radiating jaw pain.

Correct Answer is A

Explanation

Choice A reason : The symptoms described for the 40-year-old woman align closely with the clinical presentation of a pulmonary embolism. Swelling and pain in the calf may indicate deep vein thrombosis (DVT), which can lead to PE. The presence of chest pain, difficulty breathing, rapid heart rate (tachycardia), and rapid breathing (tachypnea) are hallmark signs of PE³⁴.

Choice B reason : While the 60-year-old man is experiencing fatigue, which can be a symptom of many conditions, there is no direct indication of PE. Acute kidney injury (AKI) after IV antibiotics suggests a different pathophysiology unrelated to PE.

Choice C reason : The 30-year-old man's refusal to ambulate or wear compression stockings after surgery increases his risk for DVT and subsequently PE; however, he does not currently exhibit symptoms that are as indicative of PE as the 40-year-old woman.

Choice D reason : The 55-year-old woman's symptoms could suggest a cardiac event, such as a heart attack, especially with the radiating jaw pain. While PE can present with similar symptoms, the radiating pain is more characteristic of cardiac issues³.

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A nurse is preparing a client who is to receive chemotherapy for the treatment of breast cancer. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with schizophrenia may demonstrate these positive symptoms (select all that apply) :

Correct Answer is ["A","B","C"]

Explanation

Which patient is most likely experiencing a pulmonary embolism (PE)?

Correct Answer is A

Explanation

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When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated is :

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