Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?

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Question 1 of 5

Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?

Correct Answer: A

Rationale: Clients with polycythemia vera are at an increased risk for developing blood clots due to the increased thickness of their blood. Flying long distances, especially overseas, can further increase this risk. Therefore, traveling long distances by plane can be dangerous for clients with polycythemia vera. The nurse should provide instructions to the client regarding the importance of discussing travel plans with their healthcare provider to ensure appropriate measures are in place to minimize the risk of blood clots.

Question 2 of 5

The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?

Correct Answer: C

Rationale: Marrow suppression is the major dose-limiting adverse reaction to floxuridine (FUDR). It typically becomes noticeable 2 to 4 days after drug administration. Floxuridine acts by interfering with DNA replication and is most toxic to rapidly dividing cells, such as those in the bone marrow. As a result, bone marrow suppression leading to decreased production of blood cells can occur relatively quickly after the administration of floxuridine. Monitoring for bone marrow suppression is essential in patients receiving this medication to ensure timely intervention and prevention of complications such as anemia, thrombocytopenia, and leukopenia.

Question 3 of 5

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Correct Answer: B

Rationale: A client with a cerebellar brain tumor is likely to experience impaired balance due to the location of the tumor affecting the cerebellum, which is responsible for coordinating movement and balance. Impaired balance increases the risk for falls and other injuries, making it a priority concern for the client. Therefore, adding "Related to impaired balance" to the nursing diagnosis statement would be the most appropriate choice to address the client's risk for injury in this situation.

Question 4 of 5

or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?

Correct Answer: C

Rationale: The most appropriate expected outcome for a client experiencing anxiety related to a cancer diagnosis would be "Client uses any effective method to reduce tension." This outcome focuses on the client actively managing their anxiety by utilizing various strategies to decrease tension and promote feelings of calmness. It empowers the client to take control of their anxiety and seeks to foster a sense of well-being during a difficult time. The other options do not directly address the active management of anxiety as effectively as option C.

Question 5 of 5

A very popular means of early detection of breast cancer is:

Correct Answer: D

Rationale: Breast self-examination (BSE) is a very popular means of early detection of breast cancer as it involves women being aware of how their breasts look and feel to detect any changes such as lumps, swelling, or other abnormalities. By performing regular self-examinations, women can identify any potential issues early on and seek medical advice promptly. While mammograms (X-ray) and clinical breast exams by healthcare providers are also important screening methods for detecting breast cancer, BSE is particularly valuable as women can perform it on a regular basis at home, thus increasing the chances of identifying any concerning changes promptly. It is recommended that women perform BSE monthly to become familiar with their breast tissue and notice any changes over time.

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