Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a postmenopausal client prescribed the aromatase inhibitor, anastrozole, for the treatment of breast cancer. Which of the following should the nurse tell the client she may experience?
A. High calcium levels.
High calcium levels are not typically associated with the use of anastrozole, an aromatase inhibitor. Aromatase inhibitors work by blocking the conversion of androgens to estrogens, and they do not directly impact calcium levels.
B. Muscle and joint pain.
Muscle and joint pain is a common side effect of aromatase inhibitors like anastrozole. These medications can lead to musculoskeletal discomfort, including joint stiffness and pain, which the nurse should inform the client about to ensure she is aware of potential adverse effects.
C. Heart failure.
Heart failure is not a known side effect of anastrozole. The drug's primary concern is its impact on the musculoskeletal system, particularly causing joint and muscle pain.
D. Polyphagia.
Polyphagia, which refers to excessive hunger and increased food intake, is not associated with the use of anastrozole. This choice is unrelated to the side effects of the medication and can be ruled out.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
High calcium levels are not typically associated with the use of anastrozole, an aromatase inhibitor. Aromatase inhibitors work by blocking the conversion of androgens to estrogens, and they do not directly impact calcium levels.
Choice B rationale:
Muscle and joint pain is a common side effect of aromatase inhibitors like anastrozole. These medications can lead to musculoskeletal discomfort, including joint stiffness and pain, which the nurse should inform the client about to ensure she is aware of potential adverse effects.
Choice C rationale:
Heart failure is not a known side effect of anastrozole. The drug's primary concern is its impact on the musculoskeletal system, particularly causing joint and muscle pain.
Choice D rationale:
Polyphagia, which refers to excessive hunger and increased food intake, is not associated with the use of anastrozole. This choice is unrelated to the side effects of the medication and can be ruled out.
Similar Questions
A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression?
A. Hormonal changes with a rapid decline in estrogen and progesterone levels.
Hormonal changes play a significant role in postpartum depression. After childbirth, there is a rapid decline in estrogen and progesterone levels, which can lead to mood fluctuations and depressive symptoms. Understanding this hormonal aspect is crucial for the nurse to address postpartum depression risk factors.
B. Increased social support systems.
Increased social support systems would be considered a protective factor against postpartum depression rather than a risk factor. Having strong social support can help mitigate the risk of developing postpartum depression.
C. High self-esteem.
High self-esteem is not typically a risk factor for postpartum depression. In fact, individuals with higher self-esteem may be more resilient in coping with the challenges of postpartum period.
D. Mother of two other children.
Being a mother of two other children is not inherently a risk factor for postpartum depression. While having multiple children can be demanding, it does not directly increase the risk of developing postpartum depression. The hormonal changes and individual circumstances play more significant roles.
Full Explanation
Choice A rationale:
Hormonal changes play a significant role in postpartum depression. After childbirth, there is a rapid decline in estrogen and progesterone levels, which can lead to mood fluctuations and depressive symptoms. Understanding this hormonal aspect is crucial for the nurse to address postpartum depression risk factors.
Choice B rationale:
Increased social support systems would be considered a protective factor against postpartum depression rather than a risk factor. Having strong social support can help mitigate the risk of developing postpartum depression.
Choice C rationale:
High self-esteem is not typically a risk factor for postpartum depression. In fact, individuals with higher self-esteem may be more resilient in coping with the challenges of postpartum period.
Choice D rationale:
Being a mother of two other children is not inherently a risk factor for postpartum depression. While having multiple children can be demanding, it does not directly increase the risk of developing postpartum depression. The hormonal changes and individual circumstances play more significant roles.
A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
A. Increased pancreatic activity during pregnancy causes fat intolerance.
Increased pancreatic activity during pregnancy causing fat intolerance is not related to the cause of indigestion and heartburn. Pancreatic activity can change during pregnancy, but it does not directly impact indigestion and heartburn.
B. Increased estrogen production causes more hydrochloric acid in the stomach.
Increased estrogen production causing more hydrochloric acid in the stomach is not the cause of indigestion and heartburn during pregnancy. While hormones can influence digestion, the mechanism for indigestion and heartburn lies elsewhere.
C. Pressure from the growing uterus pushes up on the stomach and intestines.
Pressure from the growing uterus pushing up on the stomach and intestines is a contributing factor to indigestion and heartburn during pregnancy. However, it is not the primary cause. The main cause is related to the relaxation of the cardiac sphincter.
D. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux.
Progesterone causes relaxation of the cardiac sphincter, which is a muscular valve that prevents stomach acid from flowing back into the esophagus. When this sphincter relaxes, it can lead to acid reflux and subsequent indigestion and heartburn during pregnancy. The nurse should educate the client about this hormonal effect to help manage these symptoms effectively.
Full Explanation
Choice A rationale:
Increased pancreatic activity during pregnancy causing fat intolerance is not related to the cause of indigestion and heartburn. Pancreatic activity can change during pregnancy, but it does not directly impact indigestion and heartburn.
Choice B rationale:
Increased estrogen production causing more hydrochloric acid in the stomach is not the cause of indigestion and heartburn during pregnancy. While hormones can influence digestion, the mechanism for indigestion and heartburn lies elsewhere.
Choice C rationale:
Pressure from the growing uterus pushing up on the stomach and intestines is a contributing factor to indigestion and heartburn during pregnancy. However, it is not the primary cause. The main cause is related to the relaxation of the cardiac sphincter.
Choice D rationale:
Progesterone causes relaxation of the cardiac sphincter, which is a muscular valve that prevents stomach acid from flowing back into the esophagus. When this sphincter relaxes, it can lead to acid reflux and subsequent indigestion and heartburn during pregnancy. The nurse should educate the client about this hormonal effect to help manage these symptoms effectively.
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
A. Palpate the client's uterine fundus.
Palpating the client's uterine fundus is an essential nursing intervention after childbirth to assess for uterine atony or excessive bleeding. However, in this scenario, the client has already saturated two perineal pads with blood in a short period, indicating active bleeding. Therefore, the priority is to take immediate action to stop the bleeding, rather than assessing the uterine fundus.
B. Assist the client on a bedpan to urinate.
Assisting the client on a bedpan to urinate is important for postpartum care and can help prevent bladder distension and discomfort. However, it is not the priority in this situation where the client is experiencing significant postpartum bleeding. Managing the bleeding is the primary concern at this time.
C. Prepare to administer oxytocic medication.
The correct priority nursing intervention is to prepare to administer oxytocic medication. Oxytocic drugs, such as oxytocin (Pitocin), are used to stimulate uterine contractions and prevent or treat postpartum hemorrhage. Administering this medication promptly can help control the bleeding and prevent further complications.
D. Increase the client's fluid intake.
Increasing the client's fluid intake may be beneficial for postpartum hydration, especially if the client has lost a significant amount of blood. However, it is not the priority in this situation. Managing the postpartum bleeding takes precedence, and if intravenous fluids are needed, they can be given concurrently with the administration of oxytocic medication.
Full Explanation
A. Palpating the client's uterine fundus is the priority intervention because excessive postpartum bleeding could indicate uterine atony, where the uterus fails to contract effectively. Assessing the fundus will help determine if it is boggy and if fundal massage is needed to promote uterine contraction and reduce bleeding.
B. Assisting the client to urinate is an important intervention if the bladder is distended, as a full bladder can prevent the uterus from contracting properly. However, palpating the fundus to assess the source of bleeding takes priority over assisting with urination.
C. Preparing to administer oxytocic medication may be necessary if the uterine fundus is boggy and does not respond to massage, but the first step is to assess the fundus and attempt manual intervention before proceeding with medication.
D. Increasing the client's fluid intake can help maintain circulation and prevent dehydration, but it does not address the immediate concern of postpartum hemorrhage. Palpating the fundus is the priority action in this scenario