The physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guerin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:

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: Anticholinesterase drugs. These drugs increase acetylcholine levels at neuromuscular junctions, helping improve muscle strength in myasthenia gravis. Adrenergic drugs (B) and beta-blocker drugs (D) are not typically used to treat muscle weakness in myasthenia gravis. Anticholinergic drugs (C) can worsen symptoms by blocking acetylcholine receptors, making them an inappropriate choice for this condition.

Correct Answer: A

Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls. Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall. Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall. Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.

Correct Answer: C

Rationale: Step 1: Patients with Grave's disease who undergo thyroidectomy require regular follow-up care for monitoring thyroid hormone levels and overall health. Step 2: Regular follow-up care ensures early detection of any complications or recurrence of the disease. Step 3: Monitoring helps in adjusting medication doses and managing any potential side effects. Step 4: Choice A is important but not specific to thyroidectomy for Grave's disease. Choice B is not typically used post-thyroidectomy. Choice D may be beneficial but not a priority compared to regular follow-up care.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.

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: 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: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting. Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.