Study questions

A client w/a diagnosis of cancer is receiving epoetin alfa (Epogen, Procrit) as part of the treatment regime. The nurse evaluates the effectiveness of the drug by:

Monitoring the hematocrit and hemoglobin Monitor CBC for elevated RBC and Hgb

The nurse is preparing a client for a thyroid test. Which medications that the client is taking should be documented on the laboratory slip as possibly affecting the thyroid test?

Phenytoin Metoclopramide Furosemide Amphetamine Explanation: If a client has recently taken a drug that contains iodine or has had radiographic contrast studies that used iodine, thyroid test results may be inaccurate. Other drugs also affect the results of thyroid tests. Phenytoin can lower T4 values. Metoclopramide can raise TSH levels. Amphetamine can lower TSH levels. Furosemide can increase T4 level. Be sure to enter on the laboratory request slip all drugs the client is taking or has taken within the past 3 months. The other drugs do not have relevance to the thyroid test.

An older adult in the hospital with a fractured hip is being prepared for surgical repair. The bilateral hearing aids were forgotten at the client's home and the client is having difficulty hearing. To promote communication, which of the following actions should the nurse perform? Select all answers that apply.

Talk directly to the client. Use a deeper tone of voice. Ask the client to repeat what was stated. Explanation: Actions that a nurse can take to help a client with hearing loss include the following: talk directly to the client; use a deep tone rather than a high tone; and ask the client to repeat what was stated to ensure understanding. The nurse does not speak in a loud voice, because in doing so, the nurse would use a higher tone, which is more difficult to hear. The nurse should minimize background noises in the room by turning off the television.

Which statement related to "wonder drug" aspirin is FALSE?

Aspirin selectively blocks COX2 but not 1.

A pt is being placed on a purine-restricted diet. What food should be suggested by the nurse?

Dairy products

Symptoms of myxedema coma

Decreased LOC, respirations, and blood pressure.

Choose the most likely reason why a nurse should question the use of demerol for pain management in an eldery pt:

Decreased binding of meperidine by plasma protein

Allopurinol has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic findings?

Decreased platelets.

Goiter S/S

Enlarged Thyroid Hypo or Hyperthyroid, or Euthyroid Dysphagia Difficulty Breathing hoarsness cough Dizziness, when lifting arms over head

meds for rheumatoid arthritis

Etanercept adalimumab Methotrexate

Meds that Suppress release of Thyroid Hormones

Sodium iodine Potassium iodine Dexamethasone Saturated solution of potassium iodine (SSKI)

Which intervention should the nurse implement to manage pain for the client with rheumatoid arthritis? SATA:

Support joints w.splints and pillows Provide diversional activities Provide opportunities for the client to verbalize feelings

The immune abnormalities that characterize systemic lupus erythematosus (SLE) include which of the following? SATA: (might need to be in order)

Susceptibility Abnormal innate and adaptive immune responses Autoantibodies immune complexes Inflammation Damage

What is the first line drug for an adult client with osteoporosis to prevent fractures?

Teriparatide

Gout starts where?

The big toe

anterior pituitary hormones

GH, TSH, ACTH, FSH, LH, PRL ,MSH

DMARD used to treat rheumatoid arthritis

Hydroxychloroquine (Plaquenil)

A client presents at the clinic reporting weight loss despite an increased appetite. For which condition should this client be assessed?

Hyperthyroidism

A physician orders lab tests to confirm hyperthyroidism in a client w/classic s/s of this disorder. Which test result would confirm the diagnosis?

No increases in TSH level after 30 minutes during the TSH stimulation test.

After cancer chemo, a client experiences nausea and vomiting. The nurse should assign highest priority to which?:

Administering metoclopramide and dexamethasone as ordered.

Labs for osteomalacia

Blood test - low levels of vitamin D, Calcium, Phosphorus, and elevated ALP Serum phos (LOW) Serum Calcium (low) Slightly reduced Vitamin D ( low) Elevated ALP. Low urine excretion of calcium and Cr. Can also work for lab serum calcium, phosphorus, ALP, Urine test, shows low calcium and creatinine, Bone biopsy shows increased amount of osteoid. (demineralized, cartilaginous bone matrix called prebone)

A pt is having an exacerbation of RA in the morning. What intervention would be best?

A warm bath and immobilization.

Diabetes insipidus s/s

-Polyuria -Polydipsia -Fatigue -Symptoms of dehydration (dry mucous membranes, hypotension, dizziness, poor skin turgor Extreme and constant thirst that can't be quenched (polydipsia) 2-20L/day Excessive amounts of urine (polyuria) Colourless and dilute urine instead of pale yellow. Waking frequently through the night to urinate. Dry skin. Constipation. Weak muscles. Bedwetting.

Which laboratory tests would the nurse anticipate being ordered by the provider to confirm a diagnosis of systemic lupus erythematosus (SLE)?

Anti-DNA antibody test (positive) Antinuclear antibody (ANA) test (positive) LE (Lupus Erythematosus) cell test (positive) Total serum complement (decreased) elevated C-reactive protein (CRP) elevated erythrocyte sedimentation rate (ESR), decreased C3 and C4 serum complement

Which of the following classes of antineoplastic agents is cell cycle-specific?

Antimetabolites (5FU)

Which disorder does the RN understand is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex?

Cushing's syndrome

A client is diagnosed with a simple goiter and asks the nurse what caused it. What is the nurse's best response?

Excess TSH

A pt w/an acute exacerbation of arthritis is temporarily confined to bed. What position can the nurse recommend to prevent flexion deformities?

Prone

Health teaching for a pt w/diabetes who is prescribed Humulin N, an intermediate NPH insulin would include which of the following advice?

"You should take your insulin after you eat breakfast and dinner."

A pt is admitted to the hospital w/an acute gout attack. The nurse expects which medication will be ordered to treat acute gout?

Colchicine

Nursing interventions for pain in RA

Monitor for pain Position, elevation, ice and heat, distraction Analgesics

Which of the following is the nurse's primary concern when providing end of life care for a client and the family? SATA:

Providing personal care Maintaining client comfort Supporting family members

Osteoporosis Risk Factors (ACCESS)

A-lcohol Use C-orticosteroid Use C-alcium low E-strogen low S-moking S-edentary lifestyle/s ACCESS leads to OSTEOPOROSIS Dietary deficiencies (Ca, Protein, Vitamin D,C,K)

Cardinal sign of Spinal tumor

Back pain (low-back pain). Prone position is painful. Spinal Cord Compression Causes back pain, usually before neurological deficits occur.

A pt is having diagnostic testing for suspected hyperthyroidism. Which of the following diagnostics correlates w/this endocrine disorder? SATA:

Decrease in TSH Increase in T3 AND T4 Increase in radioactive iodine uptake

The nurse is caring for a client who has been diagnosed w/a "rheumatic disease". What nursing diagnosis will most likely apply to the client's care? SATA:

Fatigue Pain Alteration of self-concept (limitations)

Despmopressin (DDAVP) is an antidiuretic hormone that enhances the reabsorption of water in the kidneys thus reducing the occurrence of nocturia. It is taken as a tablet, nasal spray, or by injection. Decrease in symptoms indicates its working.

synthetic equivalent of ADH

What causes the release of adrenocorticotropic hormone in response to stress?

corticotropin-releasing hormone or factor

The nurse is teaching the client with a new prescription for ibandronate (Boniva) how to take the medication. Which instruction provided by the nurse is correct?

"Take 150 mg once a month on the same day of the month."

The nurse is performing an initial assessment of a client with a disability. The nurse should assess for which condition? Select all that apply.

Abuse Depression Explanation: Clients with a disability are at increased risk for physical, emotional, financial, and sexual abuse. The assessment should also include a screening for depression. The initial assessment of a client with a disability would not include an assessment for psychosis or bipolar disorder unless there client was exhibiting signs/symptoms or had a history of these disorders.

What pharmacologic therapy does the nurse anticipate administering when the patient is experiencing a thyroid storm? SATA:

Acetaminophen Iodine Propylthiouracil

Gout interventions

Administer meds such as analgesics, anti inflammatory, and uricosuric agents as prescribed. NOT ASPIRIN Cotricosteroid therapy probenecide pain meds (NSAIDS) Serum uric acid monitoring

Where would a RN place IV for a pt that is going to receive a vesicant chemotherapeutic drug?

Administered through a central line when possible If a peripheral line is used, blood return should be checked prior to administration. Never given in peripheral veins of the hand or wrist.

A client with multiple sclerosis is being discharged. The nurse understands that living with chronic conditions imposes many challenges, including the need for which accomplishments? Select all that apply.

Alleviate and manage symptoms Validate individual self-worth Validate family functioning Explanation: The challenges of living with chronic conditions include the need to accomplish the following: alleviate and manage symptoms, validate individual self-worth and family functioning, manage threats to identity, and die with dignity and comfort.

A physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis?

An above normal/positive anti-DNA test

Diagnostics to rule out tumor on back

CT scan, identifies bone legion and soft tissue problems

A nurse is providing an educational class to a group of older adults and at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended adequate intake of what nutrients?

Calcium Vitamin D

Disease process that begins when a cell is transformed by genetic mutation of cellular DNA

Cancer

TIS, N0, M0 means:

Carcinoma in situ, no abnormal regional lymph nodes, no evidence of distant metastasis.

A client with type 1 diabetes reports waking up in the middle of the night feeling nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood glucose readings have been 110 to 140 mg/dL. The client admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse plans to instruct the client to

Check blood glucose at 0300 (somogyi effect)

A client has just received stem cell transplantation as treatment for leukemia. What are the post procedural nursing interventions for clients receiving any form of stem cell transplantation?

Closely monitor the client for at least 3 months.

After administering desmopressin to a client with diabetes insipidus, which would the nurse identify as indicating drug effectiveness?

Decreased reports of thirst Also Increased serum sodium levels (on a different ?)

When malignant cells are killed (tumor lysis syndrome), intracellular contents are released into the bloodstream. This leads to which of the following? SATA:

Hyperkalemia Hyperuricemia Hyperphosphatemia

A client is experiencing the Somogyi effect. Which clinical findings will the nurse find upon assessment?

Hypoglycemia,followed by rebound hyperglycemia.

What is a complication of hyperthyroidism?

Hypothyroidism

With regard to the functioning of the thyroid gland, which is an essential element for the manufacturing of thyroxine and triiodothyronine?

Iodine

A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply.

Ketosis-prone Little or no endogenous insulin Younger than 30 years of age Explanation: Type I diabetes mellitus is associated with the following characteristics: onset any age, but usually young (<30 y); usually thin at diagnosis, recent weight loss; etiology includes genetic, immunologic, and environmental factors (e.g., virus); often have islet cell antibodies; often have antibodies to insulin even before insulin treatment; little or no endogenous insulin; need exogenous insulin to preserve life; and ketosis prone when insulin absent.

A client who is receiving a growth hormone antagonist develops acute cholecystitis. Which agent would the client most likely be receiving?

Octreotide and lanreotide have commonly been associated with the development of acute cholecystitis, cholestatic jaundice, biliary tract obstruction, and pancreatitis, which would present with abdominal pain, so patients should be taught to report this symptom.

If your patient is taking long term steroids what might we see:

Osteoporosis Hyperglycemia fluid retention skeletal muscle atrophy tapering of steroid is super important-do not stop abruptly

A client is transferred to a rehabilitation center after being treated in the hospital for a stroke. Because the client has a history of Cushing's syndrome (hypercortisolism) and chronic obstructive pulmonary disease (COPD), the nurse formulates a nursing diagnosis of:

Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion

When describing desmopressin to a group of students, the instructor explains that it is a synthetic form of:

antidiuretic hormone.

Abnormal labs in SIADH

low serum osmolality (fluid overload) hyponatremia (dilutional due to fluid overload) concentrated urine (holding onto fluids) Decreased plasma osmolality Increased urine osmolality/gravity (>100 mOsm/kg) Increased urine Na levels (<20) unless sodium intake is low. Ca not involved

Bromocriptine classification

growth hormone antaganost

Primary gout

the most common type of gout; results from one of several inborn errors of purine metabolism Primary gout results from a disorder of purine metabolism

S/S of Cushing's

truncal obesity, hypertension, diabetes mellitus, purple striae The classic picture is an adult with central obesity, with a fatty "buffalo hump" in the neck and a supraventricular area, a heavy trunk, and thin extremities. Truncal obesity, moon face, acne, abdominal striae(spider web, purple), hypertension, and pathological fractures.

Salvage Surgery for Cancer

uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach.

Client diagnosed with hypothyroidism began treatment with levothyroxine several weeks ago, telephones the clinic to report missing yesterday's dose. The nurse should base his/her response on what understanding concerning the length of the half-life of this drug?

9-10 days

To confirm a diagnosis of low back pain, which of the following diagnostic procedures would be ordered to rule out the presence of a tumor?

A bone scan is the preferred diagnostic procedure to disclose tumors in a patient with low back pain.

A client has been admitted to the critical care unit w/a diagnosis of thyroid storm. What interventions should the nurse include in this client's immediate care? SATA:

Administering beta blockers to reduce heart rate. Applying interventions to reduce client temperature

A client and family are dealing with the client's recent terminal diagnosis. A nurse identifies a nursing diagnosis of hopelessness. Which of the following would be most helpful in supporting hope for this family? Select all that apply.

Arranging for appropriate psychosocial counseling Encouraging the client to participate in care to foster control Helping to obtain support from the community Explanation: To enable, support, and foster hope in terminally ill clients and their families, nurses should encourage and support the client's control over circumstances, choices, and environment whenever possible, make referrals for psychosocial and spiritual counseling, and assist with developing supports in the home and community when none exist. Goals set should be realistic, rather than long-term. Information and feelings should be shared. The information provided also should be accurate.

A client has been admitted to the medical unit for the treatment of Paget disease. When reviewing the medication administration record, the nurse should anticipate what medication?

Bisphosphonates Explanation: Bisphosphonates are the cornerstone of Paget therapy in that they stabilize the rapid bone turnover. Alkaline phosphatase is a naturally occurring enzyme, not a drug. Calcium gluconate and estrogen are not used in the treatment of Paget disease.

The pediatric nurse understands that growth hormone (GH) deficiency can cause which disorder?

Dwarfism

A nurse is caring for a client who is suspected of having giant cell arteritis (GCA). What laboratory tests are most useful in diagnosing this rheumatic disorder? Select all that apply.

Erythrocyte sedimentation rate C-reactive protein Explanation: Simultaneous elevation in the ESR and CRP has a sensitivity of 88% and a specificity of 98% in making the diagnosis of GCA when coupled with clinical findings. Erythrocyte counts, creatinine clearance, and D-dimer are not diagnostically useful.

Patient with a brain tumor may be at increased risk for aspiration. The most important nursing intervention includes?

Evaluation of gag reflex and ability to swallow.

The nurse is instructing a health class of high school seniors on the function of the kidney. The nurse is correct to highlight which information? SATA

Excretes Waste Products Controls BP Regulate Calcium and the synthesis of vitamin D Regulates RBC production Activates growth hormone

A client has been hospitalized with myxedema. Which of the following actions will the nurse take to care for this client? Select all that apply.

Measure the client's arterial blood gases Monitor the client's oxygen saturation levels Turn and reposition the client at regular intervals Give fluids to the client with caution Explanation: Myxedema requires nursing management measures to maintain the client's vital functions. Oxygen saturation levels and arterial blood gases should be monitored and measured to determine the need for assisted ventilation. Caution should be used when giving fluids because of the risk of water intoxication. The client should be turned and positioned to minimize risks associated with immobility. Active warming should be avoided to prevent the client's oxygen demands from increasing and to prevent hypotension. Instead passive warming with a blanked is recommended.

A client is admitted with an attack of gout. What interventions are essential for this client? SATA:

Probenecid Corticosteroid therapy Pain medication Serum uric acid concentration.

You are an oncology nurse caring for a client who is taking antineoplastic agents. What symptoms must you consider when monitoring the client?

Symptoms of gout

Characteristics of Chronic Illness

The management of chronic conditions is a process of discovery. Managing chronic conditions must be a collaborative process. Chronic illness affects the entire family.

The nurse administered an analgesic to a client who was reporting pain. The medication is ordered as needed every 3 hours. Forty minutes later the client states he has had little relief. The nurse does all of the following:

evaluates the pain level using the established pain scale assesses respirations, pulse, and blood pressure consults with the healthcare provider about the client's report Explanation: The dose of the pain medication is ineffective in relieving the client's pain. The nurse evaluates client response using the same pain scale and vital signs. The nurse may need to consult with the healthcare provider and inform of the ineffectiveness of the medication. The nurse places the client in a position of comfort to enhance effectiveness of the medication now, not later. The nurse's statement delays appropriate treatment for the client.

A client, 66 years old, has just been diagnosed with multiple myeloma (a cancer of the plasma) and will be initiating chemotherapy. The nurse, in an outpatient clinic, reviews the medications the client has been taking at home. The medications include pantoprazole for gastroesophageal reflux disease (GERD) and an over-the-counter calcium supplement to prevent osteoporosis. What interventions should the nurse take? Select all that apply.

instructs the client to discontinue calcium asks about nausea and vomiting teaches the client to report abdominal or bone pain Explanation: The client with cancer is at risk for hypercalcemia from bone breakdown. The client should not take an over-the-counter calcium supplement that would increase blood levels of calcium. Signs and symptoms of hypercalcemia include nausea and vomiting. The client may also report abdominal or bone pain with cancer. The client should increase fluid intake to 2 to 4 L per day. Intake would have to be adjusted based on the client's other medical conditions. GERD would not negate an increase in fluid intake. The client most likely would have constipation with hypercalcemia, not diarrhea.

When the nurse is providing discharge teaching to a client after spinal surgery, the nurse should ensure that, for a client with residual sensory involvement,

the client is aware that extreme temperatures should not be applied to the skin. The client should be alerted to the dangers of heating devices (e.g., hot water bottles, heating pads, space heaters). Sleeping in the recumbent position (three quarters prone) can increase pain. Thus, the client should be encouraged to sleep flat with the head of the bed slightly elevated or closely follow instructions for sleep position provided by the surgeon. Although maintaining muscle strength is important in promoting ability to carry out activities of daily living, moderate exercise may not be possible. The client should follow the rehabilitation plan prescribed by the allied health professional responsible for this aspect of the client's care (e.g., the physiotherapist).

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply.

"How long have you experienced this pain?" "Please point to where you are experiencing pain." "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." "What aggravates your chest pain?" Explanation: The nurse needs to assess pain as to intensity, timing, location, and aggravating factors. Assessing frequency is important, but the statement "You've never had this pain before, have you" is leading and nontherapeutic.

While talking with a client who has been diagnosed with a terminal illness, the client asks, " Am I dying?" Which response from the nurse would be appropriate? Select all that apply.

"This must be very difficult for you." "Tell me more about what's on your mind." Explanation: The nurse needs to listen effectively and empathetically, acknowledging the client's fears and concerns. Statements such as "This must be very difficult for you" and "Tell me more about what's on your mind" address the client's concerns and help to focus the discussion on the client. Telling the client that the nurse knows how the client feels ignores the client's concerns. Saying that there is still time for a good life or telling the client to focus on what the doctor has planned ignores the client's feelings and blocks communication.

A client with diabetes calls the clinic reporting a "flu bug." What should the nurse tell the client to do? Select all that apply.

"Try to eat small amounts of carbs, if possible." "Take your usual dose of insulin." Explanation: For prevention of DKA related to illness, the client should attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours and the client should take the usual dose of insulin.

A public health nurse reviews data on chronic illness in the community over time and notes that chronic illness rates are climbing. Which factors may contribute to the increased chronic illness rates? Select all that apply.

A decrease in mortality from infectious diseases An increase in obesity rates Explanation: Chronic illness rates are climbing due in part that there is a decrease in mortality from infectious diseases and an increase in obesity rates. There is not an increase in infectious disease rates, a decrease in client education about chronic illness, or a decrease in global awareness of chronic illness.

The nurse is performing an initial assessment of an older adult resident who has just relocated to the long-term care facility. During the nurse's interview with the client, she admits that she drinks around 600 mL (20 oz) of vodka every evening. What types of cancer does this put her at risk for? Select all that apply.

Breast cancer Esophageal cancer Liver cancer Explanation: Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or smoked meats, nitrate- and nitrite-containing foods, and red and processed meats. Alcohol increases the risk of cancers of the mouth, pharynx, larynx, esophagus, liver, colorectum, and breast.

If your patient had a carcinoembryonic antigen (CEA) tumor marker that was high, what diagnostic tests might be ordered?

CEA- A blood test used to help diagnose and manage certain types of cancers. The CEA test is used especially for cancers of the large intestine and rectum. Your doctor can also use the test results to help determine if a cancer treatment is working.

A client with AML receiving chemotherapy is treated for an acute renal injury. What is the nurse's best understanding of the pathophysiology reason behind the client's injury

Chemotherapy causes an increase in kidney stone formation (tumor lysis = uric acid increase = stone formation increase)

Which factors will cause hypoglycemia in a client with diabetes? Select all that apply.

Client has not consumed food and continues to take insulin or oral antidiabetic medications. Client has not consumed sufficient calories. Client has been exercising more than usual. Explanation: Hypoglycemia can occur when a client with diabetes is not eating at all and continues to take insulin or oral antidiabetic medications, is not eating sufficient calories to compensate for glucose-lowering medications, or is exercising more than usual. Excessive sleep and aging are not factors in the onset of hypoglycemia.

A client with nonspecific signs/symptoms has gone to the primary health care provider. The client's chief complaints revolve around extreme fatigue, unplanned weight loss, and being so weak in the muscles. The diagnostic workup included a carcinoembryonic antigen (CEA) tumor marker. The CEA result was elevated. The nurse should anticipate the physician will order which of the following diagnostic tests related to the elevated CEA?

Colonoscopy Mammogram

A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply.

Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Encourage the client to explain his or her wishes. Explanation: This client lives in Oregon, one of five states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation. Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however.

A patient shows the nurse a round, firm nodule on the wrist. The pain is described as aching, with some weakness of the fingers. What treatment does the nurse anticipate assisting with? (Select all that apply.)

Corticosteroid injections Surgical excision Aspiration of the cyst Explanation: A ganglion—a collection of neurologic gelatinous material near the tendon sheaths and joints—appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. It frequently occurs in women younger than 50 years (Porth & Matfin, 2009). The swelling is locally tender and may cause an aching pain. When a tendon sheath is involved, weakness of the finger occurs. Treatment may include aspiration, corticosteroid injection, or surgical excision. After treatment, a compression dressing and immobilization splint are used.

Which of the following is an age-related change that may affect diabetes? Select all that apply.

Decreased renal function Taste changes Decreased vision Explanation: Age-related changes include decreased renal function, taste changes, decreased vision, decreased bowel motility, and decreased proprioception.

Thyroid storm is a severe form of hyperthyroidism that can be fatal if not treated. Medical management includes pharmacotherapy. Which of the following drugs have proved helpful? Select all that apply.

Hydrocortisone Acetaminophen Methimazole Iodine Explanation: Salicylates (i.e., aspirin) are contradicted because they displace thyroid hormone from binding to proteins and make hypermetabolism worse.

A client has been diagnosed with myxedema from long-standing hypothyroidism. What clinical manifestations of this disorder does the nurse recognize are progressing to myxedema coma? Select all that apply.

Hypothermia Hypotension Hypoventilation Explanation: Severe hypothyroidism is called myxedema. Advanced, untreated myxedema can progress to myxedemic coma. Signs of this life-threatening event are hypothermia, hypotension, and hypoventilation. Hypertension and hyperventilation indicate increased metabolic responses, which are the opposite of what the client would be experiencing.

The client with blindness is hospitalized following a myocardial infarction. Which care measures would the nurse take with this client? Select all that apply.

Identify self when walking into the client's room. State when the nurse is leaving the room. Orient the client to the room using a clock reference. Explanation: Suggestions when providing care to a client with low vision or blindness include identifying oneself to the client, stating when leaving the room, and orienting the client to the room. The nurse uses a normal tone of voice, not even slightly louder. The nurse does not pat service animals without the owner's prior permission.

A nursing instructor is preparing a class on pressure ulcers. Which of the following would the instructor most likely include as a possible risk factor? Select all that apply.

Immobility Anemia Increased moisture Explanation: Risk factors associated with pressure ulcer development include immobility, decreased sensory perception, anemia, decreased tissue perfusion, and increased moisture.

A woman experienced the death of her husband from a sudden myocardial infarction 5 weeks ago. The nurse recognizes that the woman will be going through the process of mourning for an extended period of time. What processes of mourning will allow the woman to accommodate the loss in a healthy way? Select all that apply.

Reinvesting in new relationships at the appropriate time Reminiscing about the relationship she had with her husband Relinquishing old attachments to her husband at the appropriate time Explanation: Six key processes of mourning allow people to accommodate to the loss in a healthy way:1.) Recognition of the loss2.) Reaction to the separation, and experiencing and expressing the pain of the loss3.) Recollection and re-experiencing the deceased, the relationship, and the associated feelings4.) Relinquishing old attachments to the deceased5.) Readjustment to adapt to the new world without forgetting the old6.) Reinvestment Reiterating her anger and renewing her lifelong commitment may be counterproductive to the mourning process.

The nurse is performing discharge teaching for a client with rheumatoid arthritis. What teachings are priorities for the client? Select all that apply.

Safe exercise Medication dosages and side effects Assistive devices Explanation: The client with rheumatoid arthritis who is being discharged to home needs information on how to exercise safely to maintain joint mobility. Medication doses and side effects are always an essential part of discharge teaching. Assistive devices, such as splints, walkers, and canes, may assist the client to perform safe self-care. Narcotics are not commonly used, and there would be no reason for dressings.

Clients must contend with chronic illness daily. Nurses relate more effectively to clients when they understand the following as characteristics of chronic illness. Choose all that apply.

The management of chronic conditions is a process of discovery. Managing chronic conditions must be a collaborative process. Chronic illness affects the entire family. Explanation: Management of chronic conditions is a process of discovery. Chronic illness affects the entire family to the point that family life can be dramatically altered. Managing chronic conditions must be a collaborative process. Chronic conditions usually involve many different phases over the course of a person's lifetime. Chronic illness involves not only treating the medical problems but may also include the psychological and social problems.

One of the functions of nursing care of the terminally ill is to support the client and his or her family as they come to terms with the diagnosis and progression of the disease process. How should nurses support clients and their families during this process? Select all that apply.

Try to appreciate and understand the illness from the client's perspective. Assist clients with performing a life review. Provide interventions that facilitate end-of-life closure. Explanation: Nurses are responsible for educating clients about their illness and for supporting them as they adapt to life with the illness. Nurses can assist clients and families with life review, values clarification, treatment decision making, and end-of-life closure. The only way to do this effectively is to try to appreciate and understand the illness from the client's perspective. The nurse's personal experiences should not normally be included and a cure is often not a realistic hope.

The nurse is teaching a client newly diagnosed with cancer about chemotherapy. The nurse tells the client he'll receive an antitumor antibiotic. The nurse knows that this type of medications is:

cell-cycle nonspecific.

The client has suffered an injury to his right leg and is reporting pain at the level of "5" on a scale of 0 to 10. The client has a history of peripheral arterial disease. The client requests nonpharmacologic interventions. What interventions are appropriate for the nurse to perform? Select all that apply.

massages the client's back and shoulders teaches the client to perform slow, rhythmic breathing turns on the television to a show the client asks to watch Explanation: Nonpharmacological interventions that promote comfort include a massage even to an unaffected area, relaxation techniques as in counted breathing, and distraction as in watching the television. Ice is not applied to an area with impaired circulation. Macrobiotic diet is an alternative therapy that may be harmful.

The nurse understands the definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Which of the following comments by a client confirm the client's understanding of the fundamental concepts of pain? Select all that apply.

"I am tired of living with this nagging pain; I'm not sure how much longer I can go on." "I would love to go to church, but my back pain is too uncomfortable to make it through the service." "I used to walk every day for exercise; pain in my knee made me stop walking." Explanation: A fundamental concept of pain is that pain is a complex phenomenon that can affect a person's psychosocial, emotional, and physical functioning. Helplessness is an emotional response to pain. Inability to continue normal activities, such as going to church, is a psychosocial consequence of pain. Inability to perform normal exercise because of pain is a physical restriction related to pain. Pain is highly personal and subjective. The client's report is the most reliable indicator of pain. The client works with the nurse and doctor to establish a pain management regimen.

Control Surgery for Cancer

(cytoreductive or "debulking") Control surgery is a debulking procedure that consists of removing a large portion of a locally invasive tumor, such as advanced ovarian cancer. Surgery decreases the number of cancer cells; therefore, it may increase the chance that other therapies will be successful.

Anorexia and cachexia are common problems at the end of life. The nurse plays an important role in managing symptoms and preventing complications. Which of the following are appropriate nursing interventions for these problems? SATA

- Encourage the pt to eat in an upright position - Recommend that the patient eats when hungry, regardless of usual meal times. - Teach the pt how to increase the nutritional value of meals (Ie, add dry milk powder)

During an annual examination, an older client tells the nurse, "I don't understand why I need to have so many cancer screening tests now. I feel just fine!" Based on knowledge of neoplastic disease and the aging immune system, what teaching should the nurse include in the client's plan of care? Select all that apply:

- Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T lymphocytes, therefore the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine screening increases the chance of finding and treating cancer early. - The increase in occurrence of autoimmune diseases with aging strongly suggests a predisposition toward various types of cancer due to the body's inability to differentiate between self and nonself. Routine screening increases the chance of finding and treating cancer early - Nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development

What is nociceptive pain?

- pain that arises from damage to or inflammation of tissue other than that of the PNS and CNS; - usually throbbing, aching, localized; - typically responds to opioids and nonopioid medications

Stages of Gouty Arthritis

4 stages of gouty arthritis: asymptomatic hyperuricemia, acute gouty arthritis, intercritical period, chronic tophaceous gout.

Side Effects- Carmustine, a chemotherapy agent, has what significant side effect?

A significant side effect of this medication is thrombocytopenia. at risk for bleeding due to decreased platelet counts (look for nosebleeds

A nurse is caring for a patient with paget's disease and is reviewing the patient's most recent lab values. Which of the following values is more characteristic of paget's disease?

An elevated Serum alkaline phosphatase level and a normal serum calcium level.

5-Fluorouracil (5FU) is classified as which type of antineoplastic agent?

Antimetabolite Antineoplastic antibiotic is a type of anticancer drug that blocks cell growth by interfering with DNA. also called anticancer antibiotic and antitumor antibiotic.

What mechanism of action do antimetabolites interfere with?

Antimetabolites act during the S phase of the cell cycle, contributing to cell destruction or preventing cell replication. Antimetabolites can cause abnormal timing of DNA synthesis

Octreotide interventions

Arrange for baseline and periodic ultrasound evaluation of the gallbladder for patients receiving octreotide

The nurse is working with a client with a chronic condition. The nurse includes which elements in the plan of care? Select all that apply.

Assessment for identity changes Interventions to manage symptoms Interventions to prevent complications Explanation: The nurse should assess for identity changes, plan interventions to manage the client's symptoms, and prevent complications of the chronic condition. Chronic conditions do not resolve spontaneously.

In assessing the joins of a pt w/RA, the nurse understands that the joints are damages by SATA:

Bony ankylosis following inflammation of the joints Invasion of pannus (abnormal layer of tissue) into the joint causing ta loss of cartilage

Somogyi effect vs. Dawn phenomenon

Both cause hyperglycemia in the morning in Diabetics *Dawn phenomenon*: Release of Growth hormone, coritsol, catecholamines in the early morning --> hyperglycemia ; in normal patients, insulin would be released to control this hyperglycemia, but in diabetics, its not able to control the sugars *Somogyi effect*: Nocturnal hypoglycemia --> causes release of Growth hormone, coritsol, catecholamines --> a rebound hyperglycemia

The nurse in the newborn nursery is assessing an infant with suspected congenital hypothyroidism. What assessment findings support this diagnosis? (Select all that apply.)

Bradycardia Feeding difficulties Lethargy

A nurse is caring for a client who is being assessed following complaints of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? Select all that apply.

Computed tomography (CT) Magnetic resonance imaging (MRI) Ultrasound X-ray Explanation: A variety of diagnostic tests can be used to address lower back pain, including CT, MRI, ultrasound, and x-rays. Angiography is not related to the etiology of back pain.

A patient is having diagnostic testing for suspected hyperthyroidism. Which of the following diagnostics correlate with this endocrine disorder? Select all that apply.

Decrease in serum thyroid-stimulating hormone (TSH) Increased T3 Increased T4 Increase in radioactive iodine uptake Explanation: Laboratory findings include a decrease in serum TSH (with primary disease), increased Ts and T4, and an increase in radioactive iodine uptake.

The root cause of cancer is damage to cellular DNA. Such damage results from multiple factors. Which of the following is a carcinogen? SATA:

Dietary substances Environmental factors Viruses Chemical agents Defective genes Medically prescribed interventions

A nurse is planning the care of a client who has been diagnosed with kidney injury, which the nurse recognizes as being a chronic condition. Which of the following descriptors apply to chronic conditions? Select all that apply.

Diseases where complete cures are rare Diseases that do not resolve spontaneously Diseases that have a prolonged course Explanation: Chronic conditions can also be defined as illnesses or diseases that have a prolonged course, that do not resolve spontaneously, and for which complete cures are unlikely or rare.

What is the most important information for the nurse to include in a teaching plan for the pt receiving allopurinol?

Do not take this medication DURING an acute attack of gout.

A nurse who provides care on an acute medical unit has observed that physicians are frequently reluctant to refer clients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply.

Financial pressures on health care providers Client reluctance to accept this type of care Advances in "curative" treatment in late-stage illness Explanation: Physicians are reluctant to refer clients to hospice, and clients are reluctant to accept this form of care. Reasons include the difficulties in making a terminal prognosis (especially for those clients with noncancer diagnoses), the strong association of hospice with death, advances in "curative" treatment options in late-stage illness, and financial pressures on health care providers that may cause them to retain rather than refer hospice-eligible clients.

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a gastrointestinal virus and has been confused the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome is made. What nursing action is a priority?

Fluid and electrolyte balance.

A client with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the client to improve the patient's nutritional intake. What foods should a client with Cushing syndrome eat to optimize health? Select all that apply.

Foods high in vitamin D Foods high in protein Foods high in calcium Explanation: Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the client in selecting appropriate foods that are also low in sodium and calories.

What is the molecular basis for cancer?

Genetic damage. Ie, alteration on cell cycle control, DNA repair, epigenetics, histone modifications

A client suspected of having acromegaly. What definitive diagnostic testing is the most reliable method of confirming acromegaly?

Glucose tolerance test in combination w/a GH measurement.

The nurse would administer desmopressin (DDAVP) cautiously, with careful monitoring, to the patient with what comorbidity? (Select all that apply.)

Hyponatremia Asthma Epilepsy

Two main causes of osteomalacia

Insufficient calcium absorption from the intestine because of a lack of dietary calcium or a deficiency of or resistance to the action of vitamin D Phosphate deficiency caused by increased renal losses or decreased intestinal absorption She seems to be focusing on what CAUSES Sometimes from vitamin D toxicity Immobility Hypoparathyroidism Low phosphate (inverse relationship with CA) Resulting in soft, weak bones that cause pain

Palliative Surgery for Cancer

Is performed in an attempt to relieve complications of cancer, such as ulceration, obstruction, hemorrhage, pain, and malignant effusion. Performed to reduce pain, relieve airway obstruction, relieve obstructions in the GI or urinary tract, relieve pressure on the brain or spinal cord, prevent hemorrhage, remove infected or ulcerated tumors, or drain abscesses.

The nurse is assessing a patient with nonproliferative (background) retinopathy. When examining the retina, what would the nurse expect to assess? Select all that apply.

Leakage of fluid or serum (exudates) Microaneurysms Focal capillary single closure Explanation: Almost all patients with type 1 diabetes and the majority of patients with type 2 diabetes have some degree of retinopathy after 20 years (ADA, 2013). Changes in the microvasculature include microaneurysms, intraretinal hemorrhage, hard exudates, and focal capillary closure.

A female client is receiving methotrexate (Mexate), 12 g/m2 I.V., to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?

Leucovorin (citrovorum factor or folic acid)

The nurse is reviewing the health record of a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory findings should the nurse anticipate? Select all that apply.

Low serum sodium High urine sodium Increased urine specific gravity

A Client diagnosed with Diabetes is demonstrating slow, deep respirations and is difficult to arouse. Which nursing intervention is directly specifically at treating this serious complication of diabetes?

Maintain an adequate intravenous fluid delivery. Kussmaul respirations result from increased glucose in blood. (hydration will dilute glucose concentration)

A client w/ DI is extremely dehydrated and is unable to take oral fluids. Fluid therapy is prescribed. Which intervention would be most important for this client?

Measuring the urine output every 30 minutes.

Which antineoplastic drugs are classified as antimetabolites? (Select all that apply.)

Mercaptopurine (Purinethol) Capecitabine (Xeloda) Fluorouracil (Adrucil)

A client who has a pituitary adenoma would report which symptoms related to the presence of this type of tumor? SATA:

Morning headaches Chiasmal syndrome (visual changes) Polydipsia Anorexia

Low phosphate (inverse relationship with CA) The nurse is concerned that a client has taken too much vitamin D. What symptoms will the client exhibit who has vitamin D excess? (Select all that apply.)

Muscle pain Polydipsia Irritability

Which would the nurse expect to assess in a patient who is to start therapy with bisphosphonates?

Muscle weakness

A nurse caring for a 78-year-old patient with a history of OA. When planning the patient's care, what goal should the nurse include?

Patient will express satisfaction with her ability to perform ADLs

Prophylactic surgery for cancer

Performed in clients with an existing premalignant condition or a known family history or genetic mutation that strongly predisposes the person to the development of cancer An attempt is made to remove the tissue or organ at risk and thus prevent the development of cancer EX: past hx of breast cancer, have them removed before getting breast cancer

A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status would the nurse attribute to the patient's metastatic brain disease?

Personality changes

What symptoms would a patient with mets to the brain exhibit?

Personality changes Neurologic signs and symptoms include headache, gait disturbances, visual impairment, personality changes, altered mentation, memory loss and confusion, focal weakness, paralysis, aphasia, and seizures.

A client has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply.

Potassium level Blood pressure Explanation: Clients with aldosteronism exhibit a profound decline in the serum levels of potassium, and hypertension is the most prominent and almost universal sign of aldosteronism. Pupillary response, peripheral pulses, and renal function are not directly affected.

What might the nurse have to assess during the bone marrow transplant procedure?

Psychological status Mood swings. Monitor for; Monitor the client to prevent sepsis Urine output, BP, electrolytes

Purpose of Glucosamine and Chondroitin

Purpose- Retards breakdown of cartilage Glucosamine may stop or slow osteoarthritis progression Chondroitin may protect cartilage against degradation.

A patient with type 2 diabetes has been managing his blood glucose levels using diet and metformin (glucophage) following an ordered increase in the patient daily dose of metformin, the nurse should prioritize which of the following assessments

Review Cr and BUN levels

A client with rheumatic disease has developed a gastrointestinal bleed. The nurse caring for the client should further assess the client for the adverse effects of what medications?

Salicylate therapy

A client was successfully treated for thyroid storm earlier in the year. In subsequent health education, the nurse should caution the client against excessive intake of what foods?

Seafood and kelp

Your older adult patient has a diagnosis of RA and has been achieving only modest relief of her symptoms with the use of NSAIDs. When creating the patient's plan of care, which nursing diagnosis would most likely be appropriate?

Self-care deficit related to fatigue and joint stiffness.

A provider asks the nurse to teach a client with low back pain how to sit in order to minimize pressure on the spine. Which teaching points would the nurse include? Select all that apply.

Sit in a straight-backed chair with arm rests. Avoid hip extension. Place feet flat on the floor. Sit with the buttocks "tucked under." Explanation: All choices are correct, except that a soft pillow support is recommended to eradicate the hollow of the back.

A patient is diagnosed with a spinal cord tumor and has had a course of radiation and chemotherapy. Two months after the completion of the radiation, the patient complains of severe pain in the back. What is pain an indicator of in a patient with a spinal cord tumor?

Spinal metastasis Explanation: Pain is the hallmark of spinal metastasis. Patients with sensory root involvement may suffer excruciating pain, which requires effective pain management.

Cancer has the tumor staged and graded based on what?

TNM Classification system that grades them based on evidence on size of primary tumor, regional lymph node metastasis, and distant metastasis.

A client being treated with desmopressin exhibits confusion and drowsiness, and reports a headache. What is the nurse's best action?

Take the client's vital signs.

A provider prescribes a subcutaneous anabolic agent for an older adult client to prevent fractures associated with osteoporosis. What is the most likely prescribed drug?

Teriparatide- a form of parathyroid hormone consisting of the first (N-terminus) 34 amino acids, which is the bioactive portion of the hormone. It is an effective anabolic (promoting bone formation) agent used in the treatment of some forms of osteoporosis. Given Subcutaneous

The nurse is caring for the client with chronic osteomyelitis of the jaw with a draining wound. Which client goal is a priority for the client? Select all that apply.

The client will experience a tolerable level of pain. The client will demonstrate wound care. The client will maintain adequate nutritional intake. Explanation: Pain is a priority problem for the client with osteomyelitis, and it can interfere with mobility of joint. In this situation, the client's jaw is the site of infection. Pain in this location can interfere with nutritional intake of the individual. Chronic osteomyelitis presents with a nonhealing ulcer over the infected bone with a connecting sinus that will intermittently and spontaneously drain pus. The client will need to be able to provide wound care in the home setting. Remaining free from injury and maintaining an effective airway clearance are not priority goals for the client.

If you're patient was postop for a spinal tumor removal and he had lost some sensation in his lower legs before the operation, the discharge instructions would include the following:

To prevent falls and pain due to fatigue and overuse, the client should be encouraged to use assistive devices such as canes, walkers and/or wheelchairs when ambulating.

Consider your patient has brain metastases and understands an appropriate nursing diagnosis is "anxiety related to lack of control over the health circumstances" What intervention might be appropriate?

The patient will be encouraged to verbalize concerns related to the disease and its treatment. Give back control, give a sense of some mastery in education. Allow them to talk about and deal with their feelings.

For which reasons are nonpharmacologic pain management techniques used? Select all that apply.

They help decrease the sensation of pain. They help decrease the distress a client experiences as a result of pain. They allow clients to match the technique to their own individual and cultural preferences. Explanation: Nonpharmacologic pain management techniques are usually used in conjunction with medications and help to decrease the sensation of pain and the distress the client experiences as a result of pain. Nonpharmacologic methods are used to complement, not replace, pharmacologic methods in cases of severe pain. Many clients find that the use of nonpharmacologic methods helps them cope better with their pain and feel they have greater control over the pain. Nonpharmacologic methods do not have any relation to a client's risk of becoming addicted to pain medications. A variety of techniques allows clients to match the technique to their own individual and cultural preferences.

Hyperthyroidism S/S

Unintentional weight loss, even when your appetite and food intake stay the same or increase. Rapid heartbeat (tachycardia) — commonly more than 100 beats a minute. Irregular heartbeat (arrhythmia) Pounding of your heart (palpitations) Increased appetite. Nervousness, anxiety and irritability. Bug eyes (not the technical term) Exophthalmos (technical term)

Hypercalcemia s/s

Vit D toxicity, immobility, hypoparathyroidism low phosphate - inverse reaction to calcium If patient is on a loop diuretic, check Ca+ lab values More frequent urination and thirst. Fatigue, bone pain, headaches. Nausea, vomiting, constipation, decrease in appetite. Forgetfulness. Lethargy, depression, memory loss or irritability. Muscle aches, weakness, cramping and/or twitches. Kidney stones???

What precautions would you take when administering a vesicant chemotherapeutic drug?

Wear appropriate PPE, Gloves, gown, eye protectors, and mas as indicated Monitor for phlebitis with IV administration Monitor for Extravasation (leakage into surrounding skin and subcutaneous tissue, which causes tissue necrosis) stop infusion, notify HCP if this occurs, Heat or ice is applied depending on med and an antidote may be injected into the site.

The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA) which can be caused by many factors, or carcinogens. What factors can be carcinogenic? Select all that apply.

dietary substances environmental factors viruses Explanation: Carcinogens include chemical agents, environmental factors, dietary substances, viruses, lifestyle factors, and medically prescribed interventions. Although age and gender may increase a person's risk for developing certain types of cancer, they are not carcinogens in and of themselves.

Thyroid storm signs and symptoms

fever chills delirium tachycardia Elevated Temperature (fever, hyperpyrexia) Tachycardia Systolic hypertension N/V/D Agitation, tremors, anxiety Irritability, agitation, restlessness, confusion, and seizures as the condition progresses. Delirium and Coma

Octreotide

growth hormone antagonist Growth hormone inhibiting hormone for hormone-secreting tumors and acromegaly

Viscosupplementation

injection of material into joint to supplement viscous properties of synovial fluid; used for treatment of osteoarthritis. NOT A CURE a. Example: Hyaluronic Acid

When a client receives vincristine, an antineoplastic agent that inhibits DNA and protein synthesis, the client needs to be informed to report which symptoms that would be expected side effects of motor neuropathy? Select all that apply.

muscle weakness cramps and spasms in the legs loss of balance and coordination Explanation: Muscle weakness, cramps and leg spasms, and loss of balance and coordination are expected side effects of motor nerve damage. Burning and tingling sensations are signs of sensory nerve damage. Alopecia is hair loss, not a motor nerve damage sign.

A client with ovarian cancer is ordered hydroxyurea (Hydrea), an antimetabolite drug. Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with:

normal cellular processes during the S phase of the cell cycle. (cell-cycle specific)

Interferon agents are used in association with chemotherapy to produce which effects?

reduce the risk of infection by shortening the period of neutropenia through bone marrow stimulation. Suppression of bone marrow = need for interferon Reduce risk of infection and neutropenia

Reconstructive Surgery for Cancer

- Performed to improve quality of life by restoring maximal function and appearance, such as breast reconstruction after mastectomy. - may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect.

Curative Surgery for Cancer

All gross and microscopic tumor is removed or destroyed

Living with chronic conditions impose challenges including the need for accomplishments like

Alleviate and manage symptoms Validate individual self-worth Validate family functioning

Which of the following are early manifestations of liver cancer? Select all that apply.

Continuous aching in the back Pain

A patient suspected of having Cushing's disease comes to the clinic. What drug might the nurse administer to test for adrenal function and responsiveness?

Corticotropin

Difference between cox-1 and Cox-2 inhibitors?

Cox-1 secrete cytoprotective mucus

The diagnosis of osteoarthritis depends on evaluation of a number of factors. A nurse understands that the first, and frequently only, sign of symptomatic OA is which of the following?

Degree of limited passive movement

What is the difference between developmental, acquired and sensory disabilities?

Developmental - occur any time from birth to 22 years of age and result in impairment of physical or mental health, cognition, speech, language, or self-care. Examples of developmental disabilities are spina bifida, cerebral palsy, and Down syndrome. Present at birth or early in life Acquired - progression of a chronic disorder, acute nontraumatic disorders, an acute or sudden injury Sensory- long-lasting condition of blindness, deafness, a severe vision or hearing impairment, and/or severe speech impediment.

Which of the following is a characteristic of diabetic ketoacidosis (DKA)? Select all that apply.

Elevated blood urea nitrogen (BUN) and creatinine Rapid onset More common in type 1 diabetes Explanation: DKA is characterized by an elevated BUN and creatinine, rapid onset, and it is more common in type 1 diabetes. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is characterized by the absence of urine and serum ketones and a normal arterial pH level.

A pt w/primary hyperparathyroidism has a serum phosphorus level of 1.7 and Ca of 14. Which nursing action should be included in the plan of care?

Encourage 4000mL of fluids/day

A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in status would a nurse attribute to a patient's metastatic brain disease?

Neurologic signs and symptoms include headache, gait disturbances, visual impairment, personality changes, altered mentation, memory loss and confusion, focal weakness, paralysis, aphasia, and seizures

Hyperosmolar Hyperglycemic Syndrome (HHS) 1st intervention

Fluid replacement- 2-3 liters immediately The client should receive a fluid bolus of 500 ml of normal saline solution Treat with isotonic Sodium chloride before administering insulin, if you administer the insulin first the circulating volume is reduced and it is ineffective. Dextron, isotonic NS once they are stable.

Chemotherapeutic agents have different specific classifications. The following medications are antineoplastic antibiotics except:

Fluorouracil (Adrucil) Antimetabolite antineoplastic agent

The nurse is working with a coalition that is creating a global strategy to prevent and control diabetes. The nurse suggests which strategies? Select all that apply.

Focusing on healthy lifestyle programming Monitoring incidence and prevalence rates Creating policies for diabetes prevention Partnering with the American Diabetes Association Explanation: Diabetes is a chronic condition. Global action plans for the prevention and control of chronic illness include interventions such as programs to promote healthy lifestyles to reduce modifiable risk factors for chronic illness. Global action plans should also include monitoring incidence and prevalence rates, creating policy for prevention of chronic illness, and developing partnerships to prevent and control chronic illness.

A client with Cushing syndrome has been hospitalized after a fall. The dietician consulted with the client to improve the patient's nutritional intake. What foods should a client with Cushing syndrome eat to optimize health? Select all that apply.

Foods high in vitamin D Foods high in protein Foods high in calcium

A client is brought to the emergency department by the paramedics. The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome (HHS). The nurse should identify what components of HHS? Select all that apply:

Glycosuria Dehydration Hypernatremia Hyperglycemia

Which anterior pituitary hormone directly targets tissue

Growth Hormone and Prolactin

Nateglinide/ pegvisomant/ somavert

Growth hormone receptor antagonist

While providing care to a client near death, the nurse is helping the family to prepare by teaching them what to expect. Which of the following would the nurse include in the teaching plan as a sign of approaching death? Select all that apply.

Gurgling as the client breathes through the mouth Decrease in amount of urine produced Refusal to ingest food or fluids Explanation: As death approaches, a client typically has secretions that collect in the back of the throat and rattle or gurgle as the client breathes through the mouth. Breathing may become irregular with periods of no breathing. Urine output may decrease in amount and frequency, and loss of bladder and bowel control may occur. The person approaching death shows less interest in eating and drinking; for many, refusal of food is an indicator that they are ready to die. Vision and hearing may be somewhat impaired and speech may be difficult to understand.

The nurse is caring for a client admitted to the medical-surgical unit after an injury. The client states "I hurt so bad. I suffer from chronic pain anyway, and now it is so much worse." When planning the client's care, what variables should the nurse consider? Select all that apply.

How the presence of pain affects clients and families Resources that can assist the client with pain management The advantages and disadvantages of available pain relief strategies Explanation: Nurses should understand the effects of chronic pain on clients and families and should be knowledgeable about pain relief strategies and appropriate resources to assist effectively with pain management. There is no evidence of cognitive deficits in this client and the difference between acute and intermittent pain has no immediate bearing on this client's care.

Osteoarthritis vs Rheumatoid Arthritis

OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints. OA intervention: encourage weight loss and increase in aerobic activity

Somogyi effect

If the pt has a normal or elevated blood glucose concentration at bedtime, which decreases to hypoglycemic levels at 2 to 3 am, and subsequently increases as a result of the production of counterregulatory hormones.

A nurse is providing care for a client who has a recent diagnosis of Paget disease. When planning this client's nursing care, interventions should address what? Select all that apply.

Impaired physical mobility Acute pain Disturbed auditory sensory perception Risk for injury Explanation: Clients with Paget disease are at risk of decreased mobility, pain, hearing loss, and injuries resulting from decreased bone density. Paget disease does not affect blood glucose levels.

Osteomyelitis labs

Increased White Blood Cells (WBC) Estimated Sedimentation Rate (ESR) Elevated C-Reactive Protein

A 36-year-old mother of three was recently diagnosed with a chronic illness. The nurse prepared information for the patient on how to manage her illness. To help her cope with the shock and resentment that she was experiencing, the nurse gave her facts about her illness with honesty and empathy. Which of the following are the best comments that the nurse can include when talking to the patient about chronic illness? Select all that apply.

It is characterized by a progressive decline in normal physiologic function It can be associated with exacerbations and remissions. It results in residual disability due to non-reversible pathology. Explanation: Chronic illnesses are often defined as medical illnesses or health problems with associated symptoms or disabilities that require long-term management (3 months or longer). Chronic illness refers to diseases that are caused by non-reversible pathology; are characterized by a slow progressive decline in normal physiological function; are permanent with cure unlikely; and require long-term surveillance, leaving residual disability.

osteomalacia vs osteoporosis

Osteomalacia results from a defect in the bone-building process, Osteomalacia is a generalized bone condition in which there is inadequate mineralization of bone. There are two main causes of osteomalacia: osteoporosis develops due to a weakening of previously constructed bone. Osteoporosis is associated with prolonged low intake of calcium and represents a total-body calcium deficit; loss of bone mass

Diagnosis of osteoarthritis (OA) is complicated because initial joint changes occur w/out symptoms. Therefore, a combination of physical assessment and X-Ray review is necessary for a diagnosis. Select TWO signs tat, when combined, are sensitive indicators of OA.

Osteophytes Joint space narrowing

Which of the following are clinical manifestations of impingement syndrome? Select all that apply.

Pain Shoulder tenderness Limited movement Muscle spasms Atrophy Explanation: The patient experiences pain, shoulder tenderness, limited movement, muscle spasms, and atrophy. The process may progress to a rotator cuff tear.

The nurse is caring for a client at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the client? Select all that apply.

Pallor Rapid respiratory rate Hypotension Explanation: The client at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.

The nurse is preparing a client for a thyroid test. Which medications that the client is taking should be documented on the laboratory slip as possibly affecting the thyroid test?

Phenytoin Metoclopramide Furosemide Amphetamine

A client diagnosed with a malignancy is receiving an antimetabolite as part of medication therapy. What should the nurse teach this client about the use of antimetabolite medication?

Use safety measures due to possible dizziness, headache, and drowsiness Encourage REST Report all other drugs and alternative therapies currently being taken Cover the head at extremes of temperature

A client with type 1 diabetes has been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy. While teaching the client about continuous subcutaneous insulin therapy, the nurse should tell him that the regimen includes the use of:

Rapid-acting insulin only ?Change insulin pump needle every 3 days. Intermediate acting insulin: NPH?

The LVN cares for a fair skinned client during an acute phase of gouty arthritis. Which of the following best describes how the client's affected foot will appear?

Red

Which of the following is a function of Calcitonin? SATA:

Reduces bone resorption Increases urinary excretion of Ca Increases deposition of Ca in bones

Which of the following agents suppress release of thyroid hormones? Select all that apply.

Sodium iodide Potassium iodide Dexamethasone Saturated solution of potassium iodide (SSKI) Explanation: Sodium iodide, potassium iodide, dexamethasone, and SSKI suppress the release of thyroid hormones. Methimazole blocks the synthesis of thyroid hormone.

Which agent would the nurse identify as a growth hormone agonist?

Somatropin Peds- monitor height periodically The patient will demonstrate in increase in linear growth used in a child prior to the closure of the bone epiphyses in order to exert its effects responsible for the growth of the body during childhood, especially the growth of muscles and bones

What has the greatest potential to reduce an individual's risk for developing diabetes?

Weight loss Obesity is a major modifiable risk factor for diabetes.

The nurse is performing a shift assessment of a client with aldosteronism. What assessments should the nurse include? Select all that apply.

Urine output Blood pressure Explanation: The principal action of aldosterone is to conserve body sodium. Alterations in aldosterone levels consequently affect urine output and BP. The client's peripheral pulses, risk of VTE, and skin integrity are not typically affected by aldosteronism.

A client has cancer of the neck and is receiving external beam radiation therapy to the site. The client is experiencing trauma to the irradiated skin. The nurse does all of the following. (Select all that apply.)

assesses the client for any sun exposure avoids shaving the irradiated skin Explanation: The client receiving external beam radiation therapy may experience trauma to the irradiated skin. To prevent further skin damage, the client is to avoid sun exposure and shaving the irradiated skin area. Other skin areas are not damaged, only the irradiated skin. Lukewarm water is to be used to bathe the area. Water of extreme temperature should be avoided. Many over-the-counter ointments contain metals and may cause additional skin damage.

What symptoms might the patient have with tumor lysis syndrome?

early symptoms: - Restlessness, irritability - Weakness, fatigue - Numbness, tingling - n/v - Diarrhea - Muscle cramping - Joint pain - Oliguria, cloudy urine If left untreated, it could lead to severe symptoms: - Loss of muscle control - Cardiac arrhythmias - Seizures - Hallucinations, delirium GOUT like symptoms - buildup of uric acid, malaise, pruritus (itchy)

The nurse is teaching a client about carcinogens. What carcinogens does the nurse include in the teaching? Select all that apply.

dietary substances environmental factors viruses chemical agents defective genes hormone replacement therapy Explanation: Carcinogens include chemical agents, environmental factors, dietary substances, viruses, defective genes, and medically prescribed interventions such as hormone replacement therapy.

When are ketones present

"Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy."

Hyperparathyroidism relationship with kidney stones

- caused by renal damage from the precipitation of calcium phosphate in the renal pelvis and parenchyma

polymyalgia rheumatica tx

-Low dose prednisone (10-20) Treatment- Corticosteroids, such as prednisone Tapering is required to stop it. Suddenly stopping can cause hypovolemic shock, adrenal crisis, (too little corticosteroids in your body, needs gradual to adapt) Random Quizlet: What CCS can be initiated for PMR? (give dose and regimen) Prednisone 10-20mg/day

Goiter causes

-lack of iodine in the diet -overproduction or underproduction of thyroid hormones -nodules that develop in the gland itself. -Goitrogens (foods or drugs that contain thyroid-inhibiting substances) can cause goiter Goiter- Enlarged thyroid gland; disruption somewhere in the follicular cell or iodine intake

NSAIDs influence what aspect of the pathophysiology of nociceptive pain?

NSAIDS Inhibit transduction by blocking the formation of prostaglandins in the periphery

hyperthyroidism diagnostic test result

No increase in the TSH level after 30 minutes during the TSH stimulation test.

A hospitalized, insulin dependent patient w/diabetes has been experiencing morning hyperglycemia. The pt will be awakened once or twice during the night to test blood glucose levels. The health care provider suspects that the cause is related to the Somogyi Effect. Which of the following indicators supports this diagnosis? SATA:

Normal bedtime blood glucose Increase in blood glucose from 0300 until breakfast Decrease in blood sugar to hypoglycemia level between 0200 and 0300.

A client who will undergo emergency surgery suffers from chronic depression. The nurse is performing client teaching prior to the surgery. To make the client more comfortable, which of the following actions should the nurse take? Select all answers that apply.

Wait for the client to complete speaking even when answers are slow. Face the client when speaking to the client. Address the client by title and last name. Allow extra time for this client. Explanation: Nursing interventions to promote communication with clients who have mental health challenges include allowing them extra time to provide answers and waiting for them to finish speaking. Nurses address clients by titles and last names and use first names only if doing so with other people who may be present. Nurses face clients and speak directly to them. Even though a client may not appear to be listening, this symptom may be related to the chronic depression. The nurse provides preoperative teaching.

A 67-year-old client is admitted for diagnostic studies to rule out cancer. The patient is white, married, has been employed as a landscaper for 40 years, and has a 36-year history of smoking a pack of cigarettes daily. What significant risk factors does the nurse recognize this patient has? Select all that apply.

Age Cigarette smoking Occupation Explanation: Most cancer occurs in people older than 65 years. Although the overall rate of cancer deaths has declined, cancer death rates in Black men remain substantially higher than those among White men and twice those of Hispanic men. Excessive exposure to the ultraviolet rays of the sun, especially in fair-skinned people, increases the risk of skin cancers. Factors such as clothing styles (sleeveless shirts or shorts), the use of sunscreens, occupation, recreational habits, and environmental variables, including humidity, altitude, and latitude, all play a role in the amount of exposure to ultraviolet light. Tobacco smoke, thought to be the single most lethal chemical carcinogen, accounts for at least 30% of cancer deaths in humans (Fontham et al., 2009). Smoking is strongly associated with cancers of the lung, head and neck, esophagus, stomach, pancreas, cervix, kidney, and bladder and with acute myeloblastic leukemia. Marital status is not associated with risk for cancer.

A nursing instructor is lecturing to the junior students about common misconceptions of chronic illness. The instructor asks the students to write down and share some misconceptions with one another. Which of the following are common misconceptions? Select all that apply.

Everyone has to die of something and so chronic illness should not be treated. Chronic diseases cannot be prevented. Chronic diseases mainly affect people who are rich. Explanation: Some common misconceptions about chronic illness include that because everyone has to die of something, there is nothing that can be done anyway; chronic diseases cannot be prevented; and chronic diseases mainly affect people who are rich (affluent). One truth about chronic illness is that 80% of deaths from them occur in low- and middle-income countries.

A client is receiving the cell cycle-nonspecific alkylating agent thiotepa (Thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of chemotherapy regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects?

It interferes with DNA replication and RNA transcription.

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 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

According to the TNM classification system, T0 means there is:

No evidence of primary tumor

When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to

stop the infusion if swelling is observed at the site.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply.

Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae Explanation: The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activities of the liver are impaired, and liver enzymes will increase.

Which statement best indicates that a client understands how to administer his own insulin injections?

"I wrote down the steps in case I forget what to do."

A nursing student asks the instructor why the pituitary gland is called the "master gland." What is the best response by the instructor?

"It regulates the function of other endocrine glands."

Why would a patient receive Bacille Calmette-Guerin (BCG)?

BCG is the most common intravesical immunotherapy for treating early-stage bladder cancer. It's used to help keep the cancer from growing and to help keep it from coming back. Serves as antigens that stimulate an immune response when injected into the patient, may serve as antigens that can stimulate an immune response in the hopes of eradicating malignant cells.

Nursing interventions for fatigue in RA

Balance periods of rest and activity Plan rest periods Prioritize activities to do first/early Encourage regular physical activity in addition to ROM Refer to counseling/support group

A patient has been diagnosed with Type-2 diabetes. The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe?

Biguanide

long-term growth hormone treatment

Blood sugar level Serum electrolytes X-ray of the long-bones

The nurse administers desmopressin (DDAVP) to the patient to treat diabetes insipidus. What assessment finding would indicate to the nurse that the desmopressin is producing a therapeutic effect?

Decreased urine output

Exercise lowers blood glucose levels. Which of the following are the physiologic reasons that explain this statement. Select all that apply.

Increases lean muscle mass Increases resting metabolic rate as muscle size increases Decreases total cholesterol Increases glucose uptake by body muscles Explanation: All of the options are benefits of exercise except the effect of decreasing the levels of HDL. Exercise increases the levels of HDL.

Which of the following are common primary sites of tumors that metastasize to the bone? Select all that apply

Kidney Prostate Lung Breast Ovary

Which are correct statements about the relationship between the hypothalamus and the pituitary gland? SATA:

Many endocrine glands respond to stimulation from the pituitary gland, which is connected by a stalk to the hypothalamus in the brain. Under the influence of the hypothalamus , the lobes of the pituitary gland secrete various hormones

Which population does this most often occur?

Middle-aged or older people with either type 2 or no known history of diabetes.

A client with diabetes insipidus has been administered desmopressin (DDAVP) and is now reporting drowsiness, lightheadedness, and headache. What intervention will best address this client's symptoms?

reduction in the client's dose of desmopressin

What is the clinical use of tumor markers?

screening general population screening high-risk population confirm diagnosis estimate prognosis determine response to therapy Recurrence Understand new methods of diagnosing/determining prognosis of tumor markers.

A client with cancer is receiving chemotherapy and reports to the nurse that his or her mouth is painful and has difficulty ingesting food. What actions should the nurse take? Select all that apply.

Asks the client to open his or her mouth to facilitate inspection of the oral mucosa Instructs the client to brush the teeth with a soft toothbrush Consults with the healthcare provider about use of nystatin Explanation: The description of the client's report is stomatitis following chemotherapy treatment. The nurse should assess the oral mucosa based on the client's report of pain and difficulty eating. The client is to use a soft toothbrush to minimize trauma to the mouth. Nystatin (Mycostatin) is a topical medication that may provide healing for the client's mouth. The client avoids alcohol-based mouthwashes as these are irritants. Flossing the teeth may cause additional trauma to the mouth.

A client diagnosed with hyperthyroidism is unsure about the need for the prescribed propranolol, stating, "I looked this up online and it's for high blood pressure, not thyroid problems." What statement concerning beta-adrenergic blockers should the nurse use as a basis for the response?

It will block stimulation of the sympathetic nervous system.

Which of the following are common primary sites of tumors that metastasize to the bone? Select all that apply.

Kidney Prostate Lung Breast Ovary Explanation: The most common primary sites of tumors that metastasize to bone are the kidney, prostate, lung, breast, ovary, and thyroid.

Which are correct statements about the relationship between the hypothalamus and the pituitary gland? Select all that apply.

Many endocrine glands respond to stimulation from the pituitary gland, which is connected by a stalk to the hypothalamus in the brain. Under the influence of the hypothalamus, the lobes of the pituitary gland secrete various hormones. Explanation: Many endocrine glands respond to stimulation from the pituitary gland, which is connected by a stalk to the hypothalamus in the brain. Under the influence of the hypothalamus, the lobes of the pituitary gland secrete various hormones. Even though the pituitary gland is called the 'master gland,' the hypothalamus influences the pituitary gland. The pituitary gland is called the 'master gland' because it regulates the function of other endocrine glands.

The nurse is educating the patient with diabetes about the importance of increasing dietary fiber. What should the nurse explain is the rationale for the increase? Select all that apply.

May improve blood glucose levels Decrease the need for exogenous insulin Help reduce cholesterol levels Explanation: Increased fiber in the diet may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood (ADA, 2008b; Geil, 2008).

A nurse is providing care to a client w/primary hyperparathyroidism. Which interventions would be included in the client's care plan? SATA:

Monitor gait, balance, and fatigue level with ambulation Monitor for fluid overload

A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care. Which of the following would the nurse include in the explanation for this client? Select all that apply.

Provides pain relief Integrates spirituality Offers a team approach to care Enhances quality of life Explanation: The principles of palliative care include providing relief from pain and distressing symptoms. In the early course of disease, chemotherapy and radiation may be used to define care needed, but in the later stages, chemotherapy is typically not used. Psychological support including spirituality and bereavement counseling for family members is available. The care does not hasten nor postpone death but is aimed at enhancing a quality of the life that is remaining. A team approach meets the needs of the client and family.

Osteoporosis treatment

Teriparatide and abaloparatide are currently the only two approved anabolic agents for the treatment of osteoporosis in the United States Teriparatide (Forteo) is a subcutaneously administered anabolic agent that is taken once daily. ADULTS 100 International Units (IU) or 0.5 milliliter (mL) injected into a muscle or under the skin every other day. Alendronic acid tablet once a week (on the same day every week), first thing in the morning on an empty stomach with a large glass of tap water. Calcitonin is a human hormone that is also found in salmon. This medication is used to treat certain bone problems (e.g., Paget's disease, postmenopausal osteoporosis) and to reduce high blood levels of calcium. raloxifene- Selective estrogen receptor modulator. Comes as a tablet to take by mouth. It is usually taken once a day with or without food. Take raloxifene at around the same time every day. HOLD w/pt of hx of hip fx, hysterectomy, dvt, and htn.

The nurse is working with a client with systemic lupus erythematosus (SLE). What are the immune abnormalities characterized by SLE? Select all that apply.

susceptibility abnormal innate and adaptive immune responses autoantibodies immune complexes inflammation damage Explanation: The immune abnormalities that characterize SLE occur in five phases: susceptibility, abnormal innate and adaptive immune responses, autoantibodies immune complexes, inflammation, and damage.

A nurse is preparing to provide discharge teaching for a hospitalized 19-year-old client who is hearing impaired with functioning hearing aides. The television is on, and several of the client's fraternity brothers are present. What are potential teaching barriers for the nurse? Select all that apply.

television in use fraternity brothers Explanation: Barriers to learning include the television and visitors, which are both potential distractions. Visitors in the room do not promote privacy and confidentiality. The client's age, gender, and hearing impairment should not inhibit the nurse's ability to provide discharge teaching.