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The nurse cares for a 17-year-old girl diagnosed with cancer receiving chemotherapy. Which of the following statements indicates to the nurse that the client has a realistic perception of her health status? 1. "I will be cured after my therapy is complete." 2. "I have started buying scarves of different colors." 3. "I will be carrying a full load of classes this semester." 4. "I must have done something to cause this illness." Correct Answer: Strategy: Think about what the words mean. 1) may or may not happen 2) CORRECT— indicates the client is realistic about what may happen because of chemotherapy; obtains wig, scarves, or hats before losing hair 3) not realistic; weakness and fatigue are common side effects of chemotherapy 4) indicates blame and guilt The client is brought to the emergency department by friends who state, "He has been hanging with the wrong crowd. We are worried he is using drugs." The nurse notes that the client stares blankly and has an unsteady gait, stiff muscles, and eyes that are moving rapidly side to side and up and down. The nurse plans care. Which is MOSTimportant for the nurse to anticipate? 1. Increased adventitious breath sounds. 2. Decreased blood pressure, temperature, and pulse. 3. Aggressive behaviors. 4. Nausea, vomiting, abdominal cramping. Correct Answer: Strategy: The topic of the question is unstated. (1.) client's symptoms indicate phencyclidine piperidine (PCP) intoxication; breath sounds important to assess with any new client but not priority; respiratory arrest can occur with PCP overdose (2.) with PCP, blood pressure, temperature, and pulse are expected to increase, not decrease; overdose could even lead to a hypertensive crisis; hyperthermia can also occur (3.) CORRECT symptoms of blank stare, rigid muscles, ataxia, and nystagmus that is both vertical and horizontal indicate probable phencyclidine piperidine (PCP) intoxication; another name for PCP is angel dust; aggression in all forms is another symptom that manifests with PCP; can take the form of assault, belligerence, impulsiveness, and/or suicidality, and is very often bizarre in nature; often occurs in

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Kaplan NCLEX Questions and answers| Graded A|Kaplan Nursing Entrance Exam (Science, Math, Grammar)|Kaplan Nursing school entrance exam :)|KAPLAN PREDICTOR A 2022 Questions and Answers|Kaplan – QBANK | questions and answers 100% correct

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