Test 2 - Cancer Development, Care of Patients with Cancer, & Diabetes Mellitus

A client is learning alternate site testing (AST) for glucose monitoring. Which client statement indicates to the nurse that additional teaching is necessary?

"Alternate site testing is unsafe if I am experiencing a rapid change in glucose levels." Rationale: Patients should be taught about the lag time for blood glucose levels between the fingertip and other sites when blood glucose levels are changing rapidly and that the fingertip reading is the only safe choice at those times. Teach patients with a history of hypoglycemic unawareness not to test at alternative sites. Not all glucose monitors on the market can be used for AST.

The nurse has taught a patient with cancer ways to prevent infection. What statement by the patient indicates that more teaching is needed?

"It's alright for me to keep my pets and change the litter box." Rationale: Patients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The other statements are appropriate for self-management.

A nurse is monitoring a client's laboratory results for a fasting plasma glucose level. Within which range of a fasting plasma glucose level does the nurse conclude that a client is considered to be diabetic?

126 and 140 mg / dL Rationale: Levels < 100 mg/dL are considered normal. Levels > 100 mg/dL, but < 126 mg/dL indicate impaired fasting glucose. Levels > 126 obtained on at least two occasions are diagnostie of diabetes.

A nurse is providing community education on the seven warning signs of cancer. Which signs are included?

A sore that does not heal, changes in menstrual patterns, indigestion or trouble swallowing, and obvious change in a mole. Rationale: The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

A client with type 1 diabetes mellitus has a fingerstick glucose level of 258 mg / dL at bedtime. A prescription for sliding scale regular insulin (Novolin R) exists. What should the nurse do?

Administer the insulin as prescribed. Rationale: A value of 258 mg / dL is above the expected range of 70 to 100 mg / dL; the nurse should administer the regular insulin (Novolin R) as prescribed. Calling the health care provider is unnecessary; a prescription for insulin exists and should be implemented. Encouraging the intake of fluids is insufficient to lower a glucose level this high. Adminstering orange juice is contraindicated because it will increase the glucose level further; orange juice, a complex carbohydrate, and a protein should be given if the glucose level is too low.

Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar state (HHS)?

Administering fluid replacement. Rationale: As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.

A nurse is assessing a patient with glioblastoma. What assessment is most important?

Neurologic examination. Rationale: A glioblastoma arises in the brain. The most important assessment for this patient is the neurologic examination.

A nurse working in the diabetes clinic is evaluating a client's success with managing the medical regimen. Which is the best indication that a client with type 1 diabetes is successfully managing the disease?

Stabilization of the serum glucose. Rationale: A combination of diet, exercise, and medication is necessary to control the disease; the interaction of these therapies is reflected by the serum glucose level. Weight loss may occur with inadequate insulin. Acquisition of knowledge does not guarantee its application. Insulin alone is not enough to control the disease.

A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse?

Allowing a very tired patient to skip oral hygiene and sleep. Rationale: Even though patients may be tired, they still need to participate in hygiene to help prevent infection. The other options are all appropriate.

A group of nursing students has entered a futuristic science contest in which they have "developed" a cure for cancer. Which treatment would most likely be the winning entry?

Artificial fibronectin infusion to maintain tight adhesion of cells. Rationale: Cancer cells do not have sufficient fibronectin and so do not maintain tight adhesion with other cells. This is part of the mechanism of metastasis. Chromosome alterations in cancer cells (aneuploidy) consist of having too many, too few, or altered chromosome pairs. This does not necessarily lead to rapid cellular division. Rapid cellular migration is part of metastasis. Immortality is a characteristic of cancer cells due to too much telomerase.

A patient with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important?

Assess the patient's gait and balance. Rationale: This patient has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For patient safety, assessing gait and balance is the priority. Documentation should be complete. The patient may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating.

A patient has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important?

Assist the patient in getting out of bed. Rationale: Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the patient's risk for injury. The nurse should assist the patient when getting out of bed. Headache and fluid retention are not side effects of this drug.

A nurse working with patients who experience alopecia knows that which is the best method of helping patients manage the psychosocial impact of this problem?

Assisting the patient to pre-plan for this event. Rationale: Alopecia does not occur for all patients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the patient about the possibility and to give the patient multiple choices for preparing for this event. Not all patients will have the same reaction, but some possible actions the patient can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the patient's own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the patient that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the patient tools to manage this condition.

The nurse caring for oncology patients knows that which form of metastasis is the most common?

Bloodborne. Rationale: Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.

A client with diabetes is given instructions about foot care. The nurse determines that the instructions are understood when the client states, "I will

Break in my new shoes over the course of several weeks." Rationale: The client should examine the feet daily for signs of trauma. Protect blistered areas with dry, sterile dressings. Do not use adhesive tape to secure dressing to the skin. Soaking feet will cause maceration of the skin and should be avoided. A slower, longer period of time to break in new, stiff shoes will help prevent blisters and skin breakdown.

A patient is having a catheter placed in the femoral artery to deliver chemotherapy beads into a liver tumor. What action by the nurse is most important?

Ensuring that informed consent is on the chart. Rationale: This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority.

The nurse identifies that the dietary teaching provided for a client with diabetes is understood when the client states, "My diet

Can be planned around a wide variety of commonly used foods." Rationale: Each client should be given an individually devised diet selecting commonly used foods from the American Diabetic Association diet; family members should be included in the diet teaching. Rigid diets are difficult to follow; appropriate substitutions are permitted. Nutritional requirements are different for each individual, depending on many factors, such as activity level, degree of compliance, and physical status. Combination dishes and processed foods can be eaten when accounted for in the dietary regimen.

A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes and the other client has type 2 diabetes. The nurse determines that the main difference between newly diagnosed type 1 and type 2 diabetes is that in type 1 diabetes:

Complications are not present at the time of diagnosis. Rationale: Clinical presentation of type 1 diabetes is characterized by acute onset, and therefore there is no time to develop the long-term complications that are common with long-standing disease; 20% of newly diagnosed clients with type 2 diabetes demonstrate complications because the diabetes has gone undetected for an extended period of time. Clinical presentation of type 1 diabetes is rapid, not slow, as pancreatic beta cells are destroyed by an autoimmune process; in type 2 diabetes, the body is still producing some insulin, and therefore the onset of signs and symptoms is slow. In type 1 diabetes, clients are generally lean or have an ideal weight; 80% to 90% of clients with type 2 diabetes are overweight. Type 1 diabetes requires diet control, exercise, and subcutaneous administration of insulin, not oral medications; oral medications are used for type 2 diabetes because some insulin is still being produced.

A patient is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?

Gently inquire about advance directives. Rationale: Superior vena cava syndrome is often a late-stage manifestation. After the patient is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.

A nurse identifies that the client is experiencing a hypoglycemic reaction. Which nursing intervention should the nurse implement to relieve the symptoms associated with this reaction?

Giving 4 oz of fruit juice. Rationale: Liquids containing simple carbohydrates are most readily absorbed and thus increase the blood glucose level quickly. Although a solution of 50% dextrose may be given if the client is comatose, 5% dextrose does not supply sufficient carbohydrates. Withholding insulin will not alter the current situation. Complex carbohydrates and protein take longer to increase the blood glucose level, so they should be administered after a simple carbohydrate.

Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide?

Glyburide stimulates insulin production and release from the pancreas. Rationale: The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking glyburide because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.

The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells?

Growing in the wrong place or time is typical of benign tumors. Rationale: Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

A nurse concludes that a client has a hypoglycemic reaction to insulin. Which clinical findings support this conclusion?

Heart palpitations and weakness. Rationale: Irritability, a neuroglycopenic symptom, occurs when the glucose in the brain declines to a low level. Because the blood glucose level is decreased, the renal threshold is not exceeded, and there is no glycosuria. Hot, moist skin is consistent with hyperglycemic states. Heart palpitations, a neurogenic symptom, occur when the sympathetic nervous system responds to a rapid decline in blood glucose. Fruity odor of the breath is associated with hyperglycemia; it is caused by the breakdown of fats as a result of inadequate insulin supply. Nausea is consistent with hyperglycemia. Weakness is consistent with hypoglycemia.

A patient with cancer has anorexia and mucositis, and is losing weight. The patient's family members continually bring favorite foods to the patient and are distressed when the patient won't eat them. What action by the nurse is best?

Help the family show other ways to demonstrate love and caring. Rationale: Families often become distressed when their loved ones won't eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the patient is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the patient. Simply telling the family the patient is not able to eat does not give them useful information and is dismissive of their concerns.

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis. What is the initial intervention that the nurse should expect the health care provider to prescribe for this client?

IV fluids. Rationale: IV fluids are given to combat dehydration in ketoacidosis and to keep an IV line open for administration of medications. After electrolyte levels are evaluated, potassium may be added along with insulin. In acidosis, potassium ions initially shift from the intracellular to extracellular compartment, resulting in hyperkalemia; as acidosis is corrected, hypokalemia may occur and then potassium may be administered. NPH insulin is an intermediate-acting insulin; rapid-acting insulin is indicated in an emergency. Kayexalate is not indicated; abnormally high serum potassium levels will revert once dehydration is corrected.

A nurse is caring for a client newly diagnosed with type 1 diabetes. When the health care provider tries to regulate this client's insulin regimen, the client experiences episodes of hypoglycemia and hyperglycemia and 15 g of a simple sugar is prescribed. What is the reason this is administered when a client experiences hypoglycemia?

Increases blood glucose levels. Rationale: A simple sugar provides glucose to the blood for rapid action. Simple sugar does not inhibit glycogenesis, stimulate the release of insulin, or stimulate the storage of glucose.

A nurse is caring for several clients with type 1 diabetes, and they each have a prescription for a specific type of insulin. Which insulin does the nurse conclude has the fastest onset of action?

Insulin lispro (Humalog). Rationale: Insulin lispro (Humalog) has an onset of 0.25 hours, a peak action of 0.5 to 1.5 hours, and a duration of 3 to 4 hours. Insulin glargine (Lantus) has an onset of 1 to 1½ hours, no peak action, and a duration of 20 to 24 hours. NPH insulin (Novolin N) has an onset of 1.5 hours, a peak action of 4 to 12 hours, and a duration of 18 to 24 hours. Regular insulin (Novolin R) has an onset of 0.5 hours, a peak action of 1 to 5 hours, and a duration of 6 to 10 hours.

A nurse is caring for a client with type 1 diabetes, and the health care provider prescribes one tube of glucose gel. What is the primary reason for the administration of glucose gel to this client?

Insulin-induced hypoglycemia. Rationale: Glucose gel delivers a measured amount of simple sugars to provide glucose to the blood for rapid action. Acidosis occurs when there is an increased serum glucose level; therefore, glucose gel is not indicated. Diabetes mellitus involves a decreased insulin production. Glucose gel is not indicated in idiosyncratic reactions to insulin.

A nurse is caring for a client with a diagnosis of type 1 diabetes who has developed diabetic coma. Which element excessively accumulates in the blood to precipitate the signs and symptoms associated with this condition?

Ketones as a result of rapid fat breakdown, causing acidosis. Rationale: Ketones are produced when fat is broken down for energy. Although rarely used, sodium bicarbonate may be administered to correct the acid-base imbalance resulting from ketoacidosis; acidosis is caused by excess acid, not excess base bicarbonate. Diabetes does not interfere with removal of nitrogenous wastes. Carbohydrate metabolism is impaired in the client with diabetes.

A nurse is assessing a client experiencing a diabetic ketoacidosis (DKA). What unique response associated with DKA that is not exhibited with hyperglycemic hyperosmolar state (HHS) should the nurse identify when assessing this client?

Kussmaul respirations. Rationale: Kussmaul respirations occur in diabetic coma as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis); HHS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones.Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.

Which is an independent nursing action that should be included in the plan of care for a client after an episode of ketoacidosis?

Monitoring for signs of hypoglycemia as a result of treatment. Rationale: During treatment for acidosis, hypoglycemia may develop; careful observation for this complication should be made by the nurse. Withholding all glucose may cause insulin coma. Whole milk and fruit juices are high in carbohydrates, which are contraindicated immediately following ketoacidosis. The regulation of insulin depends on the prescription for coverage; the prescription usually depends on the client's blood glucose level rather than ketones in the urine.

A nurse administers the prescribed regular insulin (Novolin R) to a client in diabetic ketoacidosis. In addition, the nurse anticipates that the IV solution prescribed will contain potassium to replenish potassium ions in the extracellular fluid that are being

Moved into the intracellular fluid compartment because of the generalized anabolism induced by insulin and glucose. Rationale: Insulin stimulates cellular uptake of glucose and also stimulates the sodium/potassium pump, leading to the influx of potassium into cells. The resulting hypokalemia is offset by parenteral administration of potassium. Potassium is not lost from the body by profuse diaphoresis. Potassium moves from the extracellular to the intracellular compartment rather than being excreted in the urine. Anabolic reactions are stimulated by insulin and glucose administration; potassium is drawn into the intracellular compartment, necessitating a replenishment of extracellular potassium.

A nurse is assessing a client with a diagnosis of hypoglycemia. What clinical manifestations support this diagnosis?

Palpitations. Rationale: Palpitations, an adrenergic symptom, occur as the glucose level decreases; the sympathetic nervous system is activated, and epinephrine and norepinephrine are secreted, causing this response. Diaphoresis is a sympathetic nervous system response that occurs as epinephrine and norepinephrine are released. Slurred speech is a neuroglycopenic symptom; as the brain receives insufficient glucose, the activity of the CNS becomes depressed. Thirst occurs with hyperglycemia in response to dehydration associated with osmotic diuresis. Hyperventilation occurs with diabetic ketoacidosis; Kussmaul respirations are an effort to counteract the effects of a buildup of ketones as the body seeks acid-base balance.

A nurse is assessing a female patient who is taking progestins. What assessment finding requires the nurse to notify the provider immediately?

Red, warm, swollen calf. Rationale: All patients receiving progestin therapy are at risk for thromboembolism. A red, warm, swollen calf is a manifestation of deep vein thrombosis and should be reported to the provider. Irregular menses, edema in the lower extremities, and breast tenderness are common side effects of the therapy.

Four patients are receiving tyrosine kinase inhibitors (TKIs). Which of these four patients should the nurse assess first?

Patient with a serum potassium of 2.8 mEq/L (2.8 mmol/L). Rationale: TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse should assess this patient first. Dry, itchy, peeling skin can be a problem in patients receiving biologic response modifiers, and the nurse should assess that patient next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the patient with the low potassium level is more critical.

A student nurse asks the nursing instructor what "apoptosis" means. What response by the instructor is best?

Programmed cell death. Rationale: Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.

A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage?

Providing vaccinations against certain cancers, instructing people on the use of chemoprevention, and teaching teens the dangers of tanning booths. Rationale: Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.

A client tells the nurse during the admission history that an oral hypoglycemic agent is taken daily. For which condition does the nurse conclude that an oral hypoglycemic agent may be prescribed by the health care provider?

Reduced insulin production. Rationale: Oral hypoglycemics may be helpful when some functioning of the beta cells exists, as in type 2 diabetes. Rapid-acting regular insulin is needed to reverse ketoacidosis. Obesity does not offer enough information to determine the status of beta cell function. Clients with type 1 diabetes have no functioning beta cells; the necessary treatment is insulin, not an oral hypoglycemic.

A client is diagnosed with diabetic ketoacidosis. Which insulin should the nurse expect the health care provider to prescribe?

Regular insulin (Novolin R). Rationale: Regular insulin (Novolin R) is rapid-acting and should be used for diabetic coma. Insulin lispro (Humalog) is too short-acting and must be administered concurrently with a longer-acting insulin. Insulin glargine (Lantus) is a long-acting insulin, which is not indicated in an emergency. NPH insulin (Novolin N) is intermediate-acting insulin; it is not indicated for use in an emergency.

A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to

Request that if testing is further delayed, the patient be returned to the unit to eat. Rationale: Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.

The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include?

Specific morphology, nonmigratory, and differentiated function. Rationale: Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.

A client admitted to the emergency department has ketones in the blood and urine. Which situation associated with this physiologic finding should be the nurse's focus when collecting additional data about this client?

Starvation. Rationale: In starvation there are inadequate carbohydrates available for immediate energy, and stored fats are used in excessive amounts, producing ketones. There is no fat in alcohol; fat oxidation does not occur. Bone healing does not require the use of great amounts of fat; calcium is deposited to form callus. A positive nitrogen balance does not require the use of great amounts of fat.

A patient is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the patient's chart that the cancer classification is TISN0M0. What does the nurse conclude about this patient's cancer?

There are no distant metastases noted in the report. Rationale: TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis.

Which statement about carcinogenesis is accurate?

Tumor cells need to develop their own blood supply. Rationale: Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.