A nurse identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for metastatic cancer. What statement or question would be best to validate this client problem?

Correct Answer: D

Rationale: The correct answer is D because it involves collaboration with the client to validate their experience. It shows respect for the client's perspective and promotes open communication. Choice A is incorrect as it lacks client involvement. Choice B is incorrect as it focuses on the nurse's interpretation rather than the client's experience. Choice C is incorrect as it may come off as accusatory or judgmental, lacking empathy.

Correct Answer: C

Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Asking if the patient feels the need to go to the bathroom helps assess urgency. 2. Urinary retention may lead to the inability to sense the urge to void. 3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention. Summary: B: Mobility is not directly related to urinary retention. C: Medication timing is important but not directly related to urinary retention. D: Safety rail inquiry is more related to fall prevention, not urinary retention.

Correct Answer: C

Rationale: The correct answer is C: Bleeding gums and dark tarry stools. Thrombocytes are platelets responsible for blood clotting. Medications that depress thrombocytes can lead to decreased clotting ability, resulting in bleeding tendencies. Bleeding gums and dark tarry stools are common signs of bleeding due to decreased platelet function. A: Sore throat and swollen glands are more indicative of a possible infection or inflammation, not related to thrombocyte depression. B: Pernicious anemia with weakness is associated with vitamin B12 deficiency, not directly related to thrombocyte depression. D: Thickening of blood and bruising are not typical signs of decreased platelet function, but rather may be indicative of other conditions like clotting disorders.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.

Correct Answer: A

Rationale: The correct answer is A because assessment data should be collected continuously to ensure timely detection of any changes in the client's condition. This allows for prompt interventions and prevents complications. Choice B is incorrect as assessment should be ongoing and not limited to specific times. Choice C is incorrect as the frequency of assessment should be based on client needs, not a fixed schedule. Choice D is incorrect as assessments should not be limited to certain times but should be ongoing to provide comprehensive care.

Correct Answer: A

Rationale: The correct answer is A: Pregnancy. During pregnancy, the need for iron increases significantly to support the growth of the fetus and to prevent maternal anemia. Iron is essential for the production of hemoglobin and for oxygen transport in the blood. In contrast, infants require iron for rapid growth and development, making choice B partially correct. Choice C (Old age) and choice D (Male reproductive years) are incorrect as the need for iron typically decreases in old age and remains relatively stable during male reproductive years.

Correct Answer: C

Rationale: The correct answer is C: Hematuria. Bacillus Calmette-Guerin (BCG) is a type of immunotherapy used to treat bladder cancer by stimulating the immune system to attack cancer cells. One common side effect of BCG instillations is hematuria, which is the presence of blood in the urine. This occurs because BCG irritates the bladder lining, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware and can report any excessive bleeding to their healthcare provider promptly. Other choices are incorrect: A: Renal calculi - BCG therapy is not known to cause renal calculi. B: Delayed ejaculation - BCG therapy is not associated with delayed ejaculation. D: Impotence - BCG therapy is not linked to impotence.

Correct Answer: A

Rationale: The correct answer is A: Otorrhea. Otorrhea refers to the discharge of fluid from the ear, indicating an abnormal finding of ear drainage. This term specifically describes the symptom of ear drainage, making it the most appropriate choice for documenting this finding. Otalgia (choice B) refers to ear pain, ototoxic (choice C) refers to substances that are harmful to the ear, and tinnitus (choice D) refers to ringing in the ears, none of which accurately describe ear drainage. Therefore, the correct choice is A as it specifically addresses the symptom of ear drainage.