After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?

Correct Answer: C

Rationale: The correct answer is C because administering antiemetic medications like metoclopramide and dexamethasone helps control nausea and vomiting post-chemotherapy. Metoclopramide acts on the gut to reduce nausea, while dexamethasone decreases inflammation and suppresses the vomiting reflex. Choice A focuses on dietary interventions but does not address the physiological cause of nausea. Choice B with breathing exercises may help some clients but does not directly address the nausea and vomiting. Choice D is incorrect as withholding fluids can lead to dehydration, which is not recommended after chemotherapy.

Correct Answer: A

Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect. The anesthesiologist should monitor the client for this adverse reaction. Muscle rigidity and spasms are common with ketamine administration and can affect the client's comfort and safety during the procedure. It is important for the nurse to promptly address any signs of muscle rigidity or spasms to prevent complications. Summary of why other choices are incorrect: B: Hiccups - Ketamine can cause hiccups, but it is not the primary side effect to monitor for in this scenario. C: Extrapyramidal reactions - Ketamine does not typically cause extrapyramidal reactions. D: Respiratory depression - Ketamine is known for its minimal effect on respiratory depression compared to other anesthetics. Monitoring respiratory depression is still important, but not the primary concern with ketamine administration in this case.

Correct Answer: D

Rationale: The correct answer is D: Active listening. Active listening is crucial when working with a dying client and their family as it involves fully concentrating, understanding, responding, and remembering what is being said. This technique helps the nurse show empathy, build trust, and provide emotional support. By actively listening, the nurse can better understand the client's needs and concerns, which is essential in end-of-life care. Reflection (A) involves paraphrasing what the client said, which may not always be appropriate in this sensitive situation. Clarification (B) and Interpretation (C) involve adding one's own understanding or perspective, which can be intrusive and may not align with the client's feelings or beliefs.

Correct Answer: C

Rationale: The correct answer is C because asking if the client has strained their voice recently is the most relevant question to assess the issue of hopelessness. Voice strain can be a symptom of underlying emotional distress or mental health concerns, which could be contributing to the client's feelings of hopelessness. Choices A, B, and D are unrelated to the client's presenting issue and would not provide valuable information in addressing the problem at hand.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. The American Cancer Society recommends yearly mammograms after age 40 for early breast cancer detection. 2. Mammograms are most effective for women aged 40 and older in detecting breast cancer. 3. Regular mammograms can help detect breast cancer at an early stage, improving treatment outcomes. Summary of why other choices are incorrect: B: Mammograms should start at age 40, not after the birth of the first child. C: Mammograms are not recommended after the first menstrual period; they should start at age 40. D: Mammograms should be done annually after age 40, not every 3 years between ages 20 and 40.