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

Explanation

Choice A reason : Tongue thrusting and lip smacking are classic signs of tardive dyskinesia (TD), a side effect of long-term use of dopamine receptor-blocking agents like haloperidol¹. TD is characterized by repetitive, involuntary, purposeless movements, primarily affecting the facial, mouth, and tongue muscles².

Choice B reason : Fine hand tremors and pill rolling are more commonly associated with Parkinson's disease, which is a different type of movement disorder. While antipsychotic medications can cause extrapyramidal symptoms that resemble Parkinson's disease, these are not indicative of tardive dyskinesia².

Choice C reason : Urinary retention and constipation can be side effects of antipsychotic medications due to their anticholinergic effects. However, these are not symptoms of tardive dyskinesia, which specifically involves involuntary movements².

Choice D reason : Loud talking and pacing may be related to the underlying condition of acute psychosis or could be a behavioral side effect of antipsychotic medication, but they are not symptoms of tardive dyskinesia².

A. Encourage interaction with others by having the client share a room with other clients. B. Provide a calm atmosphere by placing the client in a private room. C. Create a cheerful environment by having bright drapes in the client's room. D. Promote access to activities by assigning the client to a room near the dayroom.

Correct Answer is B

Explanation

Choice A reason: Encouraging interaction with others by having the client share a room might be overwhelming for a client experiencing hypomanic episodes. Hypomania can involve irritability and impulsivity, making shared spaces potentially stressful. It's important to balance social interaction with the need for a controlled environment¹.

Choice B reason: Providing a calm atmosphere by placing the client in a private room can be beneficial for someone experiencing hypomanic episodes. A private room can reduce overstimulation and help manage symptoms like restlessness, agitation, and sleep disturbances. It allows the client to have a quiet space to retreat to, which can be crucial in managing mood swings¹².

Choice C reason: While a cheerful environment may seem beneficial, having bright drapes in the client's room could potentially contribute to overstimulation. Clients with hypomania are often sensitive to environmental stimuli, so it's important to keep the setting subdued to avoid exacerbating symptoms¹.

Choice D reason: Promoting access to activities by assigning the client to a room near the dayroom can be a double-edged sword. While it facilitates engagement in structured activities, which can be therapeutic, it also increases the risk of overstimulation due to the proximity to a potentially busy and noisy area. Careful consideration of the client's current state is necessary when making this decision¹.

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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 nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol (Haldol). The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following?

Correct Answer is A

Explanation

A nurse identifies that the environment is important when caring for a client with hypomanic episodes. What should the nurse do when caring for clients with this disorder?

Correct Answer is B

Explanation

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