Quiz 1 405

A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. In addition to informing the client's primary care provider, the nurse should perform what action? a. check the patients most recent platelet level b. ambulate the patient to promote circulatory function c.place the patient on protective isolation d. initiate measures to prevent venous thromboembolism (VTE)

A The client's signs are suggestive of thrombocytopenia, thus the nurse should check the client's most recent platelet level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated due to the risk of bleeding.

A child is brought to the emergency department by his parents because he suddenly developed a barking cough. Further assessment leads the nurse to suspect that the child is experiencing croup. What would the nurse have most likely assessed? a. inspiratory stridor b. high fever c. dysphagia d. toxic appearance

A A child with croup typically develops a bark-like cough often at night. This may be accompanied by inspiratory stridor and suprasternal retractions. Temperature may be normal or slightly elevated. A high fever, dysphagia, and toxic appearance are associated with epiglottitis.

The nurse is planning a discussion group for parents with children who have cancer. How would the nurse describe a difference between cancer in children and adults? A. Most childhood cancers affect the tissues rather than organs b. the majority of childhood cancers can be prevented c. childhood cancers are usually localized when found d. unlike adult cancers, childhood cancers are less responsive to treatment

A Childhood cancers usually affect the tissues, not the organs, as in adults. Metastasis often is present when the childhood cancer is diagnosed. Childhood cancers, unlike adult cancers, are very responsive to treatment. Unfortunately, little is known about cancer prevention in children.

A home health nurse is caring for a client with multiple myeloma. What intervention should the nurse prioritize when addressing the client's severe bone pain? A. helping the client manage the opioid analgesic regimen b. implementing distraction techniques c. teaching the client to use NSAIDs d. educating the client about the effective use of hot and cold packs

A For severe pain resulting from multiple myeloma, opioids are likely necessary. NSAIDs would likely be ineffective and are associated with significant adverse effects. Hot and cold packs as well as distraction would be insufficient for severe pain, though they may be useful as adjuncts.

Bacterial pneumonia is suspected in a 4-year-old boy with fever, headache, and chest pain. Which assessment finding would most likely indicate the need for this child to be hospitalized? a. tachypnea and retractions b. pale skin color c. fever d. oxygen sat at 96%

A Pneumonia is usually a self-limiting disease. Children with bacterial pneumonia can be successfully managed at home if the work of breathing is not severe and oxygen saturation is within normal limits. Hospitalization would most likely be required for the child with tachypnea, significant retractions, poor oral intake, or lethargy for the administration of supplemental oxygen, intravenous hydration, and antibiotics. Fever, although common in children with pneumonia, would not necessitate hospitalization. An oxygen saturation level of 96% would be within normal limits. Pallor (pale skin color) occurs as a result of peripheral vasoconstriction in an effort to conserve oxygen for vital functions; this finding also would not necessitate hospitalization.

A nurse is caring for a client with Hodgkin lymphoma at the oncology clinic. The nurse should identify what main goal of care? a. cure of disease b. enhancing quality of life c. palliation d. controlling symptoms

A The goal in the treatment of Hodgkin lymphoma is cure. Palliation is thus not normally necessary. Quality of life and symptom control are vital, but the overarching goal is the cure of the disease.

An oncology nurse recognizes a client's risk for fluid imbalance while the client is undergoing treatment for leukemia. What related assessments should the nurse include in the client's plan of care? Select all that apply. a. measure the patient's weight on a daily basis b. monitoring the patients electrolyte levels c. monitoring the patients hepatic function d. auscultating the patients lungs frequently e. measuring and recording the patients intake and output

A, B, D, E

A nurse is instituting neutropenic precautions for a child. What information would the nurse most likely include? Select all that apply. a. discouraging fresh flowers in teh childs room b. placing a mask on the child when outside the room c. avoiding rectal exams, suppositories, and enemas d. placing the child in a semiprivate room e. encouraging an intake of raw fruits and veggies

A,B,C Generally, neutropenic precautions include placing the child in a private room; avoiding rectal suppositories, enemas, and examinations; placing a mask on the child when outside the room; avoiding the intake of raw fruits and vegetables; and not permitting fresh flowers or live plants in the room.

The nurse is teaching the parent of a child with cystic fibrosis about nutrition requirements for the child. What should be included in this teaching? a. feed your child foods that are high in protein b. give your child high calorie foods and snacks c. admin water soluble vitamins d. Give your child foods high in fat e. give pancreatic enzymes with meals

A,B,E Children with cystic fibrosis (CF) have trouble digesting and absorbing nutrients. They tend to be underweight. For optimal health, their diets should be high in calories and high in protein, with the supplementation of fat soluble vitamins and pancreatic enzymes. This diet helps with growth and the optimal nutrients. The fat soluble vitamins (vitamins A, D, E and K) are needed, because children with CF have trouble absorbing fat and need the vitamin supplementation to aid in fat absorption. Water soluble vitamins (the B vitamins and vitamin C) do not aid in fat absorption. The child should not have a high-fat diet because the extra fat is difficult to digest and be absorbed. Pancreatic enzymes are necessary because they are missing due to the disease process. They are necessary to aid in digestion. They should be ingested with meals.

Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult client who is otherwise healthy. The client and the care team have collaborated and the client will soon begin induction therapy. The nurse should prepare the client for: a. hematopeietic stem cell transplantation b. an aggressive course of chemo c. radiation therapy on a daily basis d. daily treatment with targeted therapy medication's

B Attempts are made to achieve remission of AML by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks. Induction therapy is not synonymous with radiation, stem cell transplantation, or targeted therapies.

A nurse is caring for a client who has a diagnosis of acute myelocytic leukemia (AML). Assessment of which factor most directly addresses the most common cause of death among clients with leukemia? a. electrolytes levels b. infection status c. nutritional status d. liver function

B Because of the lack of mature and normal granulocytes that help fight infection, clients with leukemia are prone to infection. In clients with AML, death typically occurs from infection or bleeding. Symptoms of AML include weight loss, fever, night sweats, and fatigue, which would guide the nurse to monitor the client's nutrition and electrolytes. Gastrointestinal problems (nausea and vomiting) and electrolyte imbalances (hyperkalemia and hypocalcemia) may result from chemotherapy use. The liver is responsible for metabolism and metabolic detoxification, so monitoring liver function is important for the client who is receiving chemotherapy. These problems may contribute to and/or result in death but are not the most common cause.

A nurse is planning the care of a client who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the client's care plan, the nurse has identified a diagnosis of Risk for Injury, which should be attributed to which factor? a. left ventricular hypertrophy b. decreased bone density c. hypercoagulation d. labyrinthitis

B Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis (decreased bone density) and osteolytic lesions. Labyrinthitis is uncharacteristic, and clients do not normally experience hypercoagulation or cardiac hypertrophy as a result of multiple myeloma.

A client with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the client's care plan? a. provision of high calorie, low texture diet and appropriate oral hygiene b. protective isolation and vigilant use of standard precautions c. monitoring and treating the clients pain d. including the family in planning the clients activities of daily living

B Induction therapy causes neutropenia and a severe risk of infection. This risk must be addressed directly in order to ensure the client's survival. For this reason, infection control would be prioritized over nutritional interventions, family care, and pain, even though each of these are important aspects of nursing care.

A nurse is teaching the parents of a child diagnosed with cystic fibrosis about medication therapy. Which would the nurse instruct the parents to administer orally? a. anti-inflammatory agents b. pancreatic enzymes c. bronchodilators d. recombinant human DNase

B Pancreatic enzymes are administered orally to promote adequate digestion and absorption of nutrients. Recombinant human DNase, bronchodilators, and anti-inflammatory agents are typically administered by inhalation.

The nurse is examining a 5-year-old. Which sign or symptom is a reliable first indication of respiratory illness in children? a. increasing lethargy b. rapid, shallow breathing c. a bluish tinge to the lips d. slow, irregular breathing

B Tachypnea, or increased respiratory rate, is often the first sign of respiratory illness in infants and children. Slow, irregular breathing and increasing listlessness are signs that the child's condition is worsening. Cyanosis (a bluish tinge to the lips) or the degree of cyanosis present is not always an accurate indication of the severity of respiratory involvement.

The nurse is caring for an 8-year-old girl who has been diagnosed with leukemia and will have a variety of tests, including a lumbar puncture, before beginning chemotherapy. What action would be the priority? a. educating the family about chemo and its side effects b. educating the child and family about the testing procedures c. apply EMLA to the lumbar puncture site d. admin promoethazine as ordered for nausea

B The priority would be educating the child and family about the testing procedures so they know what to expect and understand why the tests are being performed. Applying EMLA to the lumbar puncture site will be done prior to the procedure. The family will be educated about chemotherapy and its side effects prior to the therapy beginning, and promethazine or other antiemetics will be administered once chemotherapy has begun.

The clinical nurse educator is presenting health promotion education to a client who will be treated for non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions? a. avoiding direct sun exposure in excess of 15 in daily b. avoiding highly crowded public places c. avoiding grapefruit juice and fresh grapefruit d. using an electric shaver rather than a razor

B The risk of infection is significant for these clients, not only from treatment-related myelosuppression but also from the defective immune response that results from the disease itself. Limiting infection exposure is thus necessary. The need to avoid grapefruit is dependent on the client's medication regimen. Sun exposure and the use of razors are not necessarily contraindicated.

A 5-year-old girl is diagnosed with iron-deficiency anemia and is to receive iron supplements. The child has difficulty swallowing tablets, so a liquid formulation is prescribed. After teaching the parents about administering the iron supplement, which statement indicates the need for additional teaching? a. we'll try to get her to drink lots of fluids throughout the day b. we will place the liquid in the front of her gums just below her teeth c. she needs to eat foods that are high in fiber, so she doesnt get constipated d. we need to measure the liquid carefully so that we give her the correct amount

B When giving liquid iron supplements, the liquid should be placed behind the teeth because it can stain the teeth. Iron can lead to constipation, so increased fluid and fiber intake is appropriate. The dosage needs to be measured carefully to prevent overdosing the child, leading to iron toxicity.

The nurse is caring for a child who has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management? a. use guided imagery and therapeutic touch b. initiate pain assessment w a standardized pain scale c. admin meperidine as ordered d. admin a nonsteroidal antiinflammatory drug (NSAID) as ordered

B The nurse should first initiate pain assessment with a standardized pain scale upon admission and provide frequent evaluations of pain. Administering NSAIDs or meperidine and the use of nonpharmacologic pain management techniques are all appropriate. However, the first action is to assess the child's pain to provide a baseline for future comparison.

An oncology nurse is caring for a client with multiple myeloma who is experiencing bone destruction. When reviewing the client's most recent blood tests, the nurse should anticipate which imbalance? a. hyperproteinemia b. elevated serum viscocity c. hypercalcemia d. elevated RBC

C Hypercalcemia may result when bone destruction occurs due to the disease process. Elevated serum viscosity occurs because plasma cells excrete excess immunoglobulin but would not result from bone destruction. The RBC count will decrease, not increase, resulting in anemia due to the abnormal protein produced from the malignant cells. Hyperproteinemia is defined as high protein in the blood and is commonly seen in clients with dehydration but would not result from bone destruction.

A clinic nurse is working with a client who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the client's disease? a. document the clients response to erythropoietin injections b. document the color of the clients palms and face during each visit c. follow the trends of the clients hematocrit d. follow the clients erythrocyte sedimentation rate over time

C The course of polycythemia vera can be best ascertained by monitoring the client's hematocrit, which should remain below 45%. Erythropoietin injections would exacerbate the condition. Skin tone should be observed, but is a subjective assessment finding. The client's erythrocyte sedimentation rate is not relevant to the course of the disease.

The nurse is describing the phases of treatment to a child who was diagnosed with leukemia and his parents. How would the nurse describe the induction stage? a. intense therapy to strengthen remission b. elimination of all residual leukemic cells c. rapid promotion of remission d. reduction of risk for CNS disease

C. Induction is done to rapidly produce a complete remission. Consolidation or intensification is the stage when remission is strengthened, and leukemic cell burden is reduced. Maintenance attempts to eliminate all residual leukemic cells, and CNS prophylaxis is the stage that attempts to reduce the development of CNS disease

A group of nursing students are reviewing the medications used to treat asthma. The students demonstrate understanding of the information when they identify which agent as appropriate for an acute episode of bronchospasm? a. ipatropium b. cromolyn c. salmeterol d. albuterol

D Albuterol is a short-acting β2-adrenergic agonist that is used for treatment of acute bronchospasm. Salmeterol is a long-acting β2-adrenergic agonist used for long-term control or exercise-induced asthma. Ipratropium is an anticholinergic agent used as an adjunct to β2-adrenergic agonists for treatment of bronchospasm. Cromolyn is a mast cell stabilizer used prophylactically but not to relieve bronchospasm during an acute wheezing episode

A client with a new diagnosis of leukemia is about to start treatment and expresses fear and anxiety with the prognosis. Which action is the nurse's most appropriate? a. encourage the client to call their family and discuss immediate role restructuring in both their family and professional life b. offer to call pastoral services and review hospice and or palliative care so the client can have a quiet dignified death c. communicate to the health care provider the need to provide more info to the client and family d. assess how much info is desired from the client in terms of illness, treatment, and complications.

D As with any client exhibiting anxiety and fear about a prognosis, listening should come first in order to assess how much information the client wants to have regarding the illness, treatment and potential complications. This is an ongoing assessment, since needs and interest in information changes throughout the course of treatment. Managing a client's care is a team effort, so involving the primary care provider and family is important, but not the nurse's priority action. Offering pastoral services and role restructuring has its place in treatment but should be discussed after an assessment of the client's needs. A discussion about palliative care and hospice is not appropriate at this time. Offering realistic hope is important and only after all treatment options are exhausted, or the client is diagnosed as terminal, should palliative and/or hospice care be considered.

The nurse is caring for a 13-year-old boy with acute myeloid leukemia (AML) who is experiencing feelings of powerlessness due to the effects of chemotherapy. What intervention will best help the teen's sense of control? a. acknowledging the boys feelings of anger with the disease b. providing realistic expectations of treatment and outcomes c. recognizing abilities that are unaffected by the disease d. involving the boy in decision whenever possible

D Involving the boy in the decision-making process will best help his sense of control. Whether he is included in important decisions about therapy or minor decisions like menus or dress, it will give him a sense of control over his situation. Acknowledging feelings of anger, recognizing his abilities, and providing realistic expectations will reduce body image disturbance and build self-esteem.

A child is prescribed monthly injections of vitamin B12. When developing the teaching plan for the family, the nurse would focus on which type of anemia? a.folic acid anemia b. aplastic anemia c. sickle cell anemia d. pernicious anemia

D Monthly injections of vitamin B12 are used to treat pernicious anemia. Aplastic anemia is characterized by a decrease in all blood cells necessitating a bone marrow transplant. Folic acid deficiency anemia is treated with dietary measures and possible folic acid supplementation. Sickle cell anemia is treated supportively with a focus on preventing sickling crisis, infection, and other complications.

A nurse is conducting a physical examination of a 5-year-old with suspected iron-deficiency anemia. How would the nurse evaluate for changes in neurologic functioning? a. open your mouth so i can look inside your cheeks and lips b. let me see the palms of your hands and soles of your feet c. do you have any bruises on your feet or shins d. will you show me how you walk across the room?

D Neurologic effects of iron deficiency may be demonstrated when the child's ability to sit, stand, and walk are impaired. Inspecting the mouth, looking for bruises, and checking the hands and feet provide information about signs of petechiae, purpura, or pallor.

The nurse is preparing to perform a physical examination of a child with asthma. Which technique would the nurse be least likely to perform? a. auscultation b. percussion c. inspection d. palpation

D When examining the child with asthma, the nurse would inspect, auscultate, and percuss. Palpation would not be used.

A child is in the emergency department with an asthma exacerbation. Upon auscultation, the nurse is unable to hear air movement in the lungs. What action should the nurse take first? a. start a p IV b. admin O2 c. admin corticosteroid d. admin a beta-2 adrenergic agonist

When lung sounds are unable to be heard in a child with asthma, the child is very ill. This means there is severe airway obstruction. The air movement is so severe that wheezes cannot be heard. The priority treatment is to administer an inhaled short-term bronchodilator (beta-2 adrenergic agonist). The child may require numerous inhalations until bronchodilation occurs and air can pass through the bronchi. Oxygen can be started, but until the bronchi are dilated, no oxygen can get through to the lung fields. An IV would need to be started and IV steroids administered to reduce the inflammation, but the priority is bronchodilation.

The nurse is caring for a 5-year-old client and notes respiratory rate of 45 breaths per minute, blood pressure 100/70 mm Hg, heart rate 115, temperature 101°F (38.3°C), and oxygen saturation 86%. Which diagnostic test is priority for the nurse to complete? a. Pumonary function test b. EEG c. ABG d. CBC

c. ABG The most useful diagnostic test in respiratory distress is an ABG. Knowing normal blood gas values for children is very important for evaluation and proper treatment. A CBC is a blood test used to test for disorders including anemia, infection, and leukemia. An EEG is a test used to find problems related to electrical activity of the brain. A pulmonary function test is performed to evaluate the respiratory system. Based on the findings, the child is experiencing respiratory distress and has an elevated temperature. Airway and breathing are priority over an elevated temperature. The child's blood pressure is within normal range for this age.