Exam 3
Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes?
Head injury Explanation: An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift Explanation: Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.
What does the nurse understand is the rationale for administering allopurinol for a patient receiving chemotherapy?
It lowers serum and uric acid levels. Explanation: Adequate hydration, diuresis, alkalinization of the acid crystals, and administration of allopurinol (Zyloprim) may be used to prevent renal toxicity.
Morphine sulfate has which of the following effects on the body?
Reduces preload Explanation: In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).
A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?
Aortic insufficiency Explanation: A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP.
The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock?
Septic Explanation: In the early stage of septic shock, the blood pressure may remain normal, the heart rate tachycardic, the respiratory rate increased, and fever with warm, flushed skin. The client, in the other shocks listed, usually present with different signs such as a normal body temperature, hypotension with either tachycardia or bradycardia, skin that is cool and clammy, and respiratory distress.
Which statement is true about malignant tumors?
They gain access to the blood and lymphatic channels. Explanation: By gaining access to blood and lymphatic channels, a tumor can metastasize to other areas of the body. Cells of malignant tumors are undifferentiated. Malignant tumors demonstrate variable rates of growth; however, the more anaplastic the tumor, the faster its growth. A malignant tumor grows at the periphery and sends out processes that infiltrate and destroy surrounding tissues.
Which class of antineoplastic agents is cell cycle-specific?
Antimetabolites (5-FU) Explanation: Antimetabolites are cell cycle-specific (S phase). Antitumor antibiotics, alkylating agents, and nitrosoureas are cell cycle-nonspecific.
A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed?
"I guess the doctor could not remove the entire tumor." Explanation: Debulking is a reference made when a tumor cannot be completely removed, often due to its extension far into healthy tissue. Without complete removal, this is not a cure and, the cancer cells will continue to replicate and require adjuvant therapies to prevent further invasion. The physician, not the nurse, will need to clarify the details of the surgery.
A nurse is developing a care plan for bone marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
7 to 14 days Explanation: Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.
A patient with uterine cancer is being treated with intracavitary radiation. The patient will emit radiation while the implant is in place. The nurse is aware of the precautions necessary for the provider of care and visitors. Which of the following are appropriate guidelines to follow? Select all that apply.
-Family members should stand about 6 feet from the patient. -Lead aprons should be worn to buffer the exposure. -Visitors may stay for 30 minutes or less. Explanation: Exposure for the nurse, health care provider or visitors should be limited to 30 minutes/8-hour shift. As time increases, exposure to radiation increases. The goal is to deliver safe, efficient care in the shortest amount of time.
Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode will the nurse anticipate?
Adjuvant therapy is likely. Explanation: T3 indicates a large tumor size with N1 indicating regional lymph node involvement. Although M0 suggest no metastasis, following with adjuvant (chemotherapy or radiation therapy) treatment is indicated to prevent the spread of cancer outside the lymph to other organs. The tumor staging of stage IV is indicative of palliative care.
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client?
Adrenergic drugs
Which colloid is expensive but rapidly expands plasma volume?
Albumin Explanation: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.
The nurse is conducting a screening for familial predisposition to cancer. Which element should the nurse note as a possible indication of hereditary cancer syndrome?
An aunt and uncle diagnosed with cancer Explanation: The hallmarks of hereditary cancer syndrome include cancer in two or more first-degree or second-degree relatives, early onset of cancer in family members younger than age 50, the same type of cancer in several family members, individual family members with more than one type of cancer, and a rare cancer in one or more family members.
Which type of shock occurs from an antigen-antibody response?
Anaphylactic Explanation: During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.
Which of the following advice does the nurse offer clients who are undergoing unsealed radiation therapy to reduce exposure?
Avoid kissing and sexual contact. Explanation: Clients who are undergoing unsealed radiation therapy are advised to avoid kissing and sexual contact. Clients are encouraged to drink plenty of fluids to help flush radioactive substances. Client may be asked to apply mild moisturizers and are not asked not to eat after the therapy
The nurse is caring for a client newly diagnosed with cancer. Which of the following therapies is used to treat something other than cancer?
Electroconvulsive therapy Explanation: Cancer is frequently treated with a combination of therapies using standardized protocols. Three basic methods used to treat cancer are surgery, radiation therapy, and chemotherapy. Electroconvulsive therapy (ECT) is a method of treatment for mental distress or illness.
Which of the following is a characteristic of a malignant tumor?
It gains access to the blood and lymphatic channels. Explanation: By this mechanism, the tumor metastasizes to other areas of the body. Cells of malignant tumors are undifferentiated. Malignant tumors demonstrate variable rate of growth; however, the more anaplastic the tumor, the faster its growth. A malignant tumor grows at the periphery and sends out processes that infiltrate and destroy surrounding tissues.
Which positioning strategy should be used for the client diagnosed with hypovolemic shock?
Modified Trendelenburg Explanation: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.
A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption?
Morphine Explanation: If a patient experiences chest pain, IV morphine is administered for pain relief. In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filling pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). Morphine also decreases the patient's anxiety and reduces the respiratory rate, and thus oxygen consumption.
What is the best reason for administering vasopressors after fluid therapy for a client in shock?
To prevent the vasopressors from further impairing cellular circulation Explanation: Vasopressors administered after fluid therapy increase the intravascular fluid volume, preventing the vasoconstrictive qualities from further impairing cellular circulation, which is already compromised by the effects of angiotensin. Vasopressors increase peripheral vascular resistance and raise the BP; they do not lower the BP. Administering vasopressors after fluid therapy does not aid better circulation and absorption or promote rapid metabolism and excretion of the vasopressors.
When a patient in shock is receiving fluid replacement, what should the nurse monitor frequently?
Urinary output Mental status Vital signs Explanation: Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. The patient receiving fluid replacement must be monitored frequently for adequate urinary output, changes in mental status, skin perfusion, and changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonary edema.
Your client is receiving radiation therapy. The client asks you about oral hygiene. What advice regarding oral hygiene should you offer?
Use a soft toothbrush and avoid an electronic toothbrush. Explanation: The nurse advises the client undergoing radiation therapy to use a soft toothbrush and avoid electronic toothbrushes to avoid skin lacerations. Gargling after each meal, flossing before going to bed, and treating cavities immediately are general oral hygiene instructions.
A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?
Wear personal protective equipment when handling blood, body fluids, and feces. Explanation: Chemotherapy drugs are present in the waste and body fluids of clients for 48 hours after administration. The nurse should wear personal protective equipment when handling blood, body fluids, or feces. Gloves offer minimal protection against exposure. The nurse should wear a face shield, gown, and gloves when exposure to blood or body fluid is likely. Placing incontinence pads in the regular trash container and providing a urinal or bedpan don't protect the nurse caring for the client.
What is the best way for the nurse to assess the nutritional status of a patient with cancer?
Weigh the patient daily. Explanation: Assessment of the patient's nutritional status is conducted at diagnosis and monitored throughout the course of treatment and follow-up. Early identification of patients at risk for problems with intake, absorption, and cachexia, particularly during the early stages of disease, can facilitate timely implementation of specifically targeted interventions that attempt to improve quality of life, treatment outcomes, and survival. Current weight, weight loss, diet and medication history, patterns of anorexia, nausea and vomiting, and situations and foods that aggravate or relieve symptoms are assessed and addressed.
A client who is suffering a myocardial infarction is transported to the ED by ambulance. This client is at greatest risk for developing which type of shock?
cardiogenic shock Explanation: Cardiogenic shock is caused by decreased force of ventricular contraction. Both myocardial infarction and cardiac dysrhythmia may cause cardiogenic shock. Obstructive shock is characterized by an impaired filling of heart with blood due to mechanical impediment, such as cardiac tamponade, dissecting aneurysm, or tension pneumothorax. Disruptive shock is caused by the enlargement of the vascular compartment and redistribution of intravascular fluid from arterial circulation to venous or capillary areas. Hypovolemic shock is caused by decreased blood volume with decreased filling of the circulatory system. Typical examples are hemorrhage, extreme dieresis, and third-spacing.
What is the major clinical use of dobutamine?
increase cardiac output. Explanation: Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.
A serum sodium concentration lower than 115 mEq/L (115 mmol/L) is associated with
seizure. Explanation: A serum sodium concentration lower than 115 mEq/L (115 mmol/L) is associated with seizures, abnormal reflexes, papilledema, coma, and death. Anorexia, weight gain, and myalgia are associated with serum sodium concentrations lower than 120 mEq/L.
A patient will be receiving radiation for 6 weeks for the treatment of breast cancer and asks the nurse why it takes so long. What is the best response by the nurse?
"It will allow time for the repair of healthy tissue." Explanation: In external-beam radiation therapy (EBRT), the total radiation dose is delivered over several weeks in daily doses called fractions. This allows healthy tissue to repair and achieves greater cell kill by exposing more cells to the radiation as they begin active cell division. Repeated radiation treatments over time (fractionated doses) also allow for the periphery of the tumor to be reoxygenated repeatedly, because tumors shrink from the outside inward. This increases the radiosensitivity of the tumor, thereby increasing tumor cell death.
When a patient takes vincristine, an antineoplastic agent that inhibits DNA and protein synthesis, the patient needs to be informed that he should report which of the following symptoms that would be an expected side-effect of motor neuropathy? Select all that apply.
-Muscle weakness -Cramps and spasms in the legs -Loss of balance and coordination Explanation: All the symptoms listed, except for choice A, refer to expected side effects of motor nerve damage. Burning and tingling sensations are signs of sensory nerve damage.
A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is
"You will need to practice birth control measures." Explanation: Following chemotherapy female clients may experience normal ovulation, early menopause, or permanent sterility. Clients are advised to use reliable methods of birth control until reproductivity is known.
Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode will the nurse anticipate?
Adjuvant therapy is likely. Explanation: T3 indicates a large tumor size with N1 indicating regional lymph node involvement. Although M0 suggest no metastasis, following with adjuvant (chemotherapy or radiation therapy) treatment is indicated to prevent the spread of cancer outside the lymph to other organs. The tumor staging of stage IV is indicative of palliative care.
A client presents to the emergency department with her spouse. The client appears to be in respiratory distress. The spouse states, "I think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which agent first?
Epinephrine intramuscularly Explanation: All of the interventions are indicated in the treatment of anaphylactic shock. However, IM epinephrine is administered first because of its vasoconstrictive action. IV Diphenhydramine is administered to reverse the effects of histamine, thereby reducing capillary permeability. Nebulized medications such as albuterol may be given to reverse histamine-induced bronchospasm. Fluid management is critical, as massive fluid shifts can occur within minutes due to increased vascular permeability.
The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?
Narrowed pulse pressure Explanation: Pulse pressure correlates well with stroke volume. Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Normally, the pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. Decreased or narrowing pulse pressure is an early indication of decreased stroke volume.
Which type of surgery is used in an attempt to relieve complications of cancer?
Palliative Explanation: Palliative surgery is performed to relieve complications of cancer. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach. Reference:
A client experienced hemorrhage following a gunshot to the chest and received massive amounts of fluids. The client is now stable. The nurse assesses abdominal pressure as 12 mm Hg. The most immediate nursing intervention is to
Raise the head of the client's bed. Explanation: Normal abdominal pressures are 0 to 5 mm Hg. The client may be experiencing abdominal compartment syndrome, an increase in the pressure of the abdominal cavity. This is from fluid leaking into the intra-abdominal cavity and results in elevating the client's diaphragm. Raising the head of the bed will promote easier breathing. The other options may be done by the nurse, but ensuring adequate oxygenation is the priority.
The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?
Tumor pressure against normal tissues Explanation: Benign tumors grow more slowly than malignant tumors and do not emit tumor-specific antigens or proteins. Benign tumors do not metastasize to distant sites. Benign tumors can compress tissues as it grows, which can result in impaired organ functioning.
Which type of hematopoietic stem cell transplantation (HSCT) is characterized by cells from a donor other than the patient?
Allogeneic Explanation: If the source of donor cells is from a donor other than the patient, it is termed allogeneic. Autologous donor cells come from the patient. Syngeneic donor cells are from an identical twin. Homogenic is not a type of stem cell transplant.
The nurse is caring for a client who has had a nuclear scan to aid in the diagnosis of possible cancer. The scan showed a "hot spot". What does this mean?
An area of increased concentrations of the tracer used in the scan. Explanation: Nuclear Scans: Clients ingest or receive intravenous (IV) radioisotopes (also known as tracers). After specific time intervals, images are taken of tissues that are affected by cancer or other diseases; the images distinguish tissues or portions of tissues that absorb more or less of the tracer. "Hot spots" show on an image of a tumor that has increased concentrations of the tracer, whereas "cold spots" can be the image of a tumor that has decreased concentration of the tracer. Options B, C, and D are incorrect information about hot spots.
The nurse is caring for a client who has had a nuclear scan to aid in the diagnosis of possible cancer. The scan showed a "hot spot". What does this mean?
An area of increased concentrations of the tracer used in the scan. Explanation: Nuclear Scans: Clients ingest or receive intravenous (IV) radioisotopes (also known as tracers). After specific time intervals, images are taken of tissues that are affected by cancer or other diseases; the images distinguish tissues or portions of tissues that absorb more or less of the tracer. "Hot spots" show on an image of a tumor that has increased concentrations of the tracer, whereas "cold spots" can be the image of a tumor that has decreased concentration of the tracer. Options B, C, and D are incorrect information about hot spots.
A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia?
Closely observe the client's skin for petechiae and bruising. Explanation: The nurse should closely observe the client's skin for petechiae and bruising. Daily laboratory testing may not reflect the client's condition as quickly as subtle changes in the client's skin. Performing a cardiovascular assessment every 4 hours and checking the clients history for a congenital link to thrombocytopenia don't help detect early signs and symptoms of thrombocytopenia.
A nurse has agreed to draft a medication teaching plan for a patient who is taking the hormonal agent, Aromasin, an aromatase inhibitor for postmenopausal women with breast cancer. The nurse knows that a major teaching point is to tell the patient to:
Increase her intake of calcium-rich foods. Explanation: One of the major side effects of Aromasin is hypercalcemia and the subsequent loss of bone. Therefore, the patient needs to have periodic blood work done, have bone density tests done, and follow a diet that will supply needed calcium that is being pulled from the bone tissue.
The drug interleukin-2 is an example of which type of biologic response modifier?
Cytokine Explanation: Other cytokines include interferon alfa and filgrastim. Monoclonal antibodies include rituximab, trastuzumab, and gemtuzumab. Retinoic acid is an example of a retinoid. Antimetabolites are cell cycle-specific antineoplastic agents.
The nurse is caring for a client who is scheduled for chemotherapy. Which is the best statement the nurse can make about the client experiencing chemotherapy-induced alopecia?
"The hair loss is usually temporary." Explanation: Alopecia associated with chemotherapy is usually temporary and will return after the therapy is completed. New hair growth may return unchanged, but there is no guarantee and color, texture, and quality of hair may be changed. There is no correlation between chemotherapy and delay in greying of hair. Use of wigs, scarves, and head coverings can be used by clients at any time during treatment plan.
Based on the understanding of the effects of chemotherapy, the nurse would anticipate which of the following clinical findings in a client 2 weeks post therapy?
Ease of bruising Explanation: The effects of chemotherapy can include myelosuppression, resulting in anemia or bleeding tendencies, as exhibited in ease in bruising. Elevated temperature and WBCs are signs of infection and are anticipated findings after chemotherapy treatment. Re growth of hair after alopecia can result in change of hair color but not anticipated 2 weeks post treatment.
A client presents to the emergency department after being stung by a bee, complaining of difficulty breathing. What vasoconstrictive medication should be given at this time?
Epinephrine Explanation: Anaphylactic shock is caused by a severe allergic reaction, such as to a bee sting, when patients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen- antibody reaction; specifically, an immunoglobulin E (IgE)- mediated response. Intramuscular epinephrine is administered for its vasoconstrictive action. Diphenhydramine (Benadryl) is administered IV to reverse the effects of histamine, thereby reducing capillary permeability. Dexamethasone and prednisone are corticosteroids, which treat inflammation; they do not have vasoconstrictive properties, however.
The nurse performs a breast exam on a client and finds a firm, non-moveable lump in the upper outer quadrant of the right breast that the client reports was not there 3 weeks ago. What does this finding suggest?
Malignant tumor Explanation: A fast-growing lump is suggestive of a malignant tumor. Metastasis can only be determined by cytology, not by palpation.
A patient is admitted for an excisional biopsy of a breast lesion. What intervention should the nurse provide for the care of this patient?
Provide time for the patient to discuss her concerns. Explanation: Patients who are undergoing surgery for the diagnosis or treatment of cancer may be anxious about the surgical procedure, possible findings, postoperative limitations, changes in normal body functions, and prognosis. The patient and family require time and assistance to process the possible changes and outcomes resulting from the surgery. The nurse serves as the patient advocate and liaison and encourages the patient and family to take an active role in decision making when possible. If the patient or family asks about the results of diagnostic testing and surgical procedures, the nurse's response is guided by the information that was conveyed previously. The nurse may be asked to explain and clarify information for patients and families that was provided initially but was not grasped because of anxiety and overwhelming feelings. It is important that the nurse, as well as other members of the health care team, provide information that is consistent from one clinician to another.
