NUR 211 Exam 2 Study Questions
A client with a new diagnosis of leukemia is about to start treatment and expresses fear and anxiety with the prognosis. Which action is the nurse's MOST appropriate? A. Communicate to the health care provider the need to provide more information to the client and the family. B. Assess how much information is desired from the client in terms of illness, treatment, and complications. C. Offer to call pastoral services and review hospice and/or palliative care so the client can have a quiet, dignified death. D. Encourage the client to call their family and discuss immediate role restructuring in both their families and professional life.
B. Assess how much information is desired from the client in terms of illness, treatment, and complications. Rationale: As with any client exhibiting anxiety and fear about a prognosis, listening should come first in order to assess how much info the client wants to have regarding the illness, treatment and potential complications. This is an ongoing assessment, since needs and interest in info changes throughout the course of treatment. Managing a client's care is a team effort, so involving the primary care provider and family is important, but not the nurse' s priority action. Offering pastoral services and role restructuring has its place in treatment but should be discussed after an assessment of the client's needs. A discussion about palliative care and hospice is not appropriate at this time. Offering realistic hope is important and only after all treatment options are exhausted, or the client is diagnosed as terminal, should palliative and/or hospice care be considered.
A client who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this client's needs for physical activity? A. Teach the client about the risks of immobility and the benefits of exercise. B. Assist the client to a chair during awake times, as tolerated. C. Collaborate with physical therapist to arrange for stair exercises. D. Teach the client to perform deep breathing and coughing exercises.
B. Assis the client to a chair during awake times, as tolerated. Rationale: Sitting up in a chair is preferrable to bed rest, even if a client is experiencing severe fatigue. A client who has debilitating fatigue would not likely be able to perform stair exercises. Teaching about mobility may be necessary, but education must be followed by interventions that actually involve mobility. Deep breathing and coughing reduce the risk of respiratory complications but are not substitutes for physical mobility in preventing deconditioning.
A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechia on the forearms. In addition to informing the client's primary care provider, the nurse should perform what action? A. Initiate measures to prevent venous thromboembolism (VTE). B. Check the client's most recent platelet level. C. Place the client on protective isolation. D. Ambulate the client to promote circulatory function.
B. Check the client's most recent platelet level. Rationale: The client's signs are suggestive of thrombocytopenia, thus the nurse should check the client's most recent platelet level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated due to the risk of bleeding.
A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). Which skin manifestation would the nurse expect to observe on inspection? A. Petechiae B. Erythematous rash C. Jaundice D. Skin sloughing
B. Erythematous rash Rationale: An acute cutaneous lesion consisting of an erythematous (butterfly-shaped) rash across the bridge of the nose and cheeks occurs in SLE. Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE. Clients with SLE do not typically experience jaundice or skin sloughing.
A client diagnosed with acute myeloid leukemia has just been admitted to the oncology unit. When writing this client's care plan, which potential complication should the nurse address? A. Pancreatitis B. Hemorrhage C. Arteritis D. Liver Dysfunction
B. Hemorrhage Rationale: Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates with the level and duration of platelet deficiency. The low platelet count can cause ecchymosis and petechia. Major hemorrhages also may develop when the platelet count drops to less than 10,000/mm3. The most common bleeding sources include gastrointestinal (GI), pulmonary, vaginal, and intracranial. Pancreatitis, arteritis, and liver dysfunctions are generally not complications of leukemia.
A client is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). Which assessment finding is certain to be present if the client has CLL? A. Increased number of blast cells. B. Increased lymphocyte levels. C. Intractable bone pain. D. Thrombocytopenia with no evidence of bleeding.
B. Increased lymphocyte levels. Rationale: An increased lymphocyte count (lymphocytosis) is always present in clients with CLL. Each of the other listed symptoms may ore may not be present, and none is definitive for CLL.
A nurse practitioner is assessing a client who has a fever, malaise, and a WBC count that is elevated. What principle should guide the nurse's management of the client's care? A. There is a need for the client to be assessed for lymphoma. B. Infection is the most likely cause of the client's change in health status. C. The client is exhibiting signs and symptoms of leukemia. D. The client should undergo diagnostic testing for multiple myeloma.
B. Infection is the most likely cause of the client's change in health status. Rationale: Leukocytosis is most often the result of infection. It is only considered pathologic (and suggestive of leukemia) if it is persistent and extreme. Multiple myeloma and lymphoma are not likely causes of this constellation of symptoms.
A nurse is providing care for a client who has just been diagnosed with early-stage RA. The nurse should anticipate the administrations of which medication? A. Hydromorphone B. Methotrexate C. Allopurinol D. Prednisone
B. Methotrexate Rationale: Once the diagnosis of RA is made, treatment should begin with either a nonbiologic or biologic disease-modifying antirheumatic drug (DMARD). Recommended treatment guidelines include beginning with nonbio DMARDs (methotrexate, leflunomide, sulfasalazine) or hydroxychloroquine within 3 months of disease onset. Prednisone is used in unremitting RA.
A nurse is caring for a client with acute myeloid leukemia who is preparing to undergo inductions therapy. In preparing a plan of care for this client, the nurse should assign the HIGHEST priority to which nursing diagnosis? A. Activity intonlerance B. Risk for infection C. Acute confusion D. Risk for spiritual distress
B. Risk for infection Rationale: Induction therapy places the client at risk for infection, thus this is the priority nursing diagnosis. During the time of induction therapy, the client is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Immobility, confusion, and spiritual distress are possible, but infection is the client's most acute physiologic threat.
A nurse is providing care for a client who has a rhematic disorder. The nurse's focused assessment includes the client's mood, behavior, level of consciousness, and neurologic status. Which diagnosis is most likely for this client? A. OA B. SLE C. RA D. Gout
B. SLE Rationale: SLE has a high degree of neurologic involvement and can result in central nervous system changes. The client and family members are asked about any behavioral changes, including manifestations of neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central nervous system manifestations.
A nurse is assessing a client for risk factors know to contribute to OA. What assessment finding should the nurse interpret as a risk factor? A. The client has a 30 pack-year smoking history B. The client's body mass index is 34 (obese) C. The client has primary hypertension D. The client is 58 years old
B. The client's body mass index is 34 (obese) Rationale: Risk factors for OA include obesity and previous joint damage. Risk factors of OA do not include smoking or HTN. Incidence increases with age, but a client who is 58 is not at heightened risk yet.
A nurse is planning client education for a client being discharged home with a diagnosis of rheumatoid arthritis. The client has been prescribed antimalarials for treatment, so the nurse knows to teach the client to self-monitor for what adverse effect? A. Tinnitus B. Visual changes C. Stomatitis D. Hirsutism
B. Visual changes Rationale: Antimalarials may cause vision changes; regular ophthalmologic examinations are necessary.
A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement? A. "I'll make sure I get enough exposure to sunlight to keep up my vitamin D levels." B. "I'll try to be as physically active as possible between flare-ups." C. "I'll make sure to monitor my body temperature on a regular basis." D. "I'll stop taking my steroids when I get relief from my symptoms."
C. "I'll make sure to monitor my body temperature on a regular basis." Rationale: Fever can signal an exacerbation and should be reported to the health care provider. Sunlight and other sources of ultraviolet light ma precipitate sever skin reaction and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. As well, these drugs should not be independently adjusted by the client.
A 68-year-old client with a history of rheumatic disease has persistent swelling, no stiffness, and full range of motion to his left knee after an injury sustained several months ago. X-rays revel no fracture of the extremity. Which factor is the most likely cause of the client's continued swelling? A. Degradation of cartilage B. Aging C. An inflammation process D. Reinjury not seen on x-ray results
C. An inflammation process Rationale: Inflammation is a complex physiologic process mediated by the immune system that occurs in response to harmful stimuli such as damaged cells. Inflammation is meant to protect the body from insult by removing the triggering antigen or event. But sometimes the immune system deviates from a normal response. Instead of a resolution of swelling after the triggering event has subsided, a proliferation of newly formed synovial tissue infiltrated with inflammatory cells (pannus) occurs. Degradation in rheumatic diseases cause inflammation, bone stiffening, and cartilage failure. Degradation may be the result of genetic or hormonal influences, mechanical factors, or prior joint damage. For this client, because of the full ROM, no reported prior joint damage, and no stiffness, degradation is less likely. Swelling is not a normal process of aging. Reinjury not seen on x-ray is a possibility but unlikely because the client has full ROM.
A client with RA comes into the clinic for a routine check-up. On assessment the nurse notes that the client appears to have lost some ability to function since the last office visit. What is the nurse's MOST appropriate action? A. Arrange a family meeting in order to explore assisted living options. B. Refer the client to a support group. C. Arrange for the client to be assessed in the home environment. D. Refer the client to social work.
C. Arrange for the client to be assessed in the home environment. Rationale: Assessment in the client's home setting can often reveal more meaningful data than an assessment in the health care setting. There is no indication that assisted living is a pressing need or that the client would benefit from social work or a support group.
After receiving a diagnosis of acute lymphocytic leukemia, a client is visibly distraught, stating, "I have no idea where to go from here." How should the nurse prepare to meet this clients psychosocial needs? A. Assess the client's previous experience with the health care system. B. Reassure the client that treatment will be challenging but successful. C. Assess the client's specific needs for education and support. D. Identify the client's plan of medical care.
C. Assess the client's specific needs for education and support. Rationale: In order to meet the client's needs, the nurse must first identify the specific nature of these needs. According to the nursing process, assessment must precede interventions. The plan of medical care is important, but not central to the provision of support. The client's previous health care is not a primary consideration, and the nurse cannot assure the client of successful treatment.
A client on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in clients at risk for thrombocytopenia? A. Interrupted sleep pattern B. Hot flashes C. Epistaxis D. Increased Weight
C. Epistaxis Rationale: Clients with thrombocytopenia are at risk for bleeding due to decreased platelet counts.
A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is MOST consistent with the clinical presentation of RA? A. Cool joints with decreased range of motion B. Signs of systemic infection C. Joint stiffness lasting longer than 1 hour, especially in the morning D. Visible atrophy of the knee and shoulder joints
C. Joint stiffness lasting longer than 1 hour, especially in the morning. Rational: In addition to joint pain and swelling, another classic sign of RA is joint stiffness lasting longer than 1 hour, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool.
A client with SLE asks the nurse why the client has to come to the office so often for "check-ups." Which rationale for frequent office visits would be BEST for the nurse to mention? A. Seeing the client face to face B. Ensuring that the client is taking medications as prescribed C. Monitoring the disease process and how well the prescribed treatment is working D. Drawing blood work every month
C. Monitoring the disease process and how well the prescribed treatment is working Rationale: The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease-related disabilities, and preventing complication from therapy. Management of SLE involves regular monitoring to assess disease process and therapeutic effectiveness.
A nurse is caring for a client who is being treated for leukemia in the hospital. The client was able to maintain nutritional status for the first few weeks following the diagnosis but is now exhibiting early signs and symptoms of malnutrition. In collaboration with diabetes, the nurse should implement what intervention? A. Arrange for TPN B. Facilitate placement of a PEG tube C. Provide the client with several small, soft-textured meals each day D. Assign responsibility for the client's nutrition to the client's friends and family
C. Provide the client with several small, soft-textured meals each day. Rational: For clients experiencing difficulties with oral intake, the provision of small, easily chewed meals may be beneficial. This option would be trialed before resorting to tube feeding or TPN. The family should be encouraged to participate in care, but should not be assigned full responsibility.
The nurse on the bone marrow transplant unit is caring for a client with cancer who has just begun HSCT. What is the priority nursing diagnosis for this client? A. Fatigue related to altered metabolic processes B. Altered nutrition: less than body requirements related to anorexia C. Risk for infection related to altered immunologic response D. Body image disturbance related to weight loss and anorexia
C. Risk for infection related to altered immunologic response Rationale: Risk for infections related to altered immunologic response is the priority nursing diagnosis. HSCT involves IV infusion of autologous or allogenic stem cells to promote red blood cell production in clients with compromised bone marrow or immune function, such as due to blood or bone marrow cancer. It caries and increased risk of sepsis and bleeding. The client's immunity is suppressed by the underlying condition necessitating the HSCT, the HSCT itself., and any cancer medication received.
A nurse provided care on a bone marrow transplant unit and is preparing a client for a hematopoietic stem cell transplantation (HSCT) the following day. Which information should the nurse emphasize to the client's family and friends? A. "Your family should likely gather at the beside in case there is a negative outcome." B. "Make sure the client doesn't eat any food in the 24 hours before the procedure." C. "Wear a hospital gown when you go into the client's room." D. "Do not visit if you have had a recent infection."
D. "Do not visit if you have had a recent infection." Rationale: Before HSCT, client are at a high risk for infection, sepsis, and bleeding. Visitors should not visit if they have had recent illness or vaccination. Gowns should indeed be worn but this is secondary in importance to avoiding the client's contact with ill visitors.
A 35-year-old client is admitted to the hospital reporting severe headaches, vomiting, and testicular pain. The client's blood work shows reduced numbers of platelets, leukocytes, and erythrocytes, and a high proportion of immature cells. The nurse caring for this client suspects which diagnosis? A. Acute Myeloid Leukemia (AML) B. Chronic Myeloid Leukemia (CML) C. Myelodysplastic Syndromes (MDS) D. Acute Lymphocytic Leukemia (ALL)
D. Acute Lymphocytic Leukemia (ALL) Rationale: In acute lymphocytic leukemia (ALL) manifestations of leukemic cell infiltration into other organs are more common than with other forms of leukemia, and include pain from an enlarged liver or spleen, as well as bone pain. The CNS is frequently a site for leukemic cells; thus, clients may exhibit headache and vomiting because of meningeal involvement. Other extranodal sites include the testes and breasts. All the listed types of leukemia, depending on severity and stage, can have the same blood work results. The difference is the client's signs and symptoms, which are closely associated with ALL. A large number of clients when first diagnosed with any type of leukemia are asymptomatic or have nonspecific symptoms. It is discovered on routine lab work.
Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult client who is otherwise healthy. The client and the care team have collaborated and the client will soon begin induction therapy. The nurse should prepare the client for: A. Daily treatment with targeted therapy medications. B. Radiation therapy on a daily basis. C. Hematopoietic stem cell transplantation. D. An aggressive course of chemotherapy.
D. An aggressive course of chemotherapy Rationale: Attempts are made to achieve remission of AML by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks. Induction therapy is not synonymous with radiation, stem cell transplantation, or targeted therapies.
A community health nurse is performing a visit to the home of a client who has a history of RA. On which aspect of the client's health should the nurse focus most closely during the visit? A. Understanding of RA B. Risk for cardiopulmonary complications C. Social support system D. Functional status
D. Functional status Rationale: The client's functional status is a central focus of home assessment of the client with RA. Functionality is PRIMARY concern.
A nurse is assessing a client with RA. The client expresses the intent to pursue complementary and alternative medicine (CAM) therapies. Which fact should underlie the nurse's response to the client? A. New evidence show CAM to be as effective as medical treatment B. CAM therapies negate many of the benefits of medications C. CAM therapies typically do more harm than good D. Most CAM therapies lack sufficient evidence to support them
D. Most CAM therapies lack sufficient evidence to support them. Rationale: A recent systematic review of CAM examined the efficacy of herbal medicine, acupuncture, Tai chi, and biofeedback for the treatment of RA and OA. There is not enough evidence of the effectiveness of CAM and more rigorous research is needed.
A nurse's plan of care for a client with rheumatoid arthritis includes several exercise-based interventions. What goal should the nurse prioritize? A. Maximize range of motion while minimizing exertion. B. Increase joint size and strength. C. Limit energy output in order to preserve strength for healing. D. Preserve of increase range of motion while limiting joint stress.
D. Preserve or increase range of motion while limiting joint stress Rationale: Exercise is vital to the management of rheumatic disorders. Goals should be preserving and promoting mobility and joint function while limiting stress on the joint and possible damage. Cardiovascular exertion should remain within age-based limits and individual ability, but it is not a goal to minimize exertion. Increasing joint size is not a valid goal.
A client with rheumatic disease has developed a GI bleed. The nurse caring for the client should further assess for medications that typically exacerbate this condition. Which medication applies? A. Corticosteroids B. Immunomodulators C. Antimalarials D. Salicylate therapy
D. Salicylate therapy Rationale: GI bleeding is an adverse effect that is associated with salicylates. Corticosteroids, antimalarials, and immunomodulators and do not normally have this adverse effect.
A client's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary provider has added prednisone to the client's drug regimen. What principle will guide this aspect of the client's treatment? A. The client will need daily blood testing for the duration of treatment. B. The client must stop all other drugs 72 hours before starting prednisone. C. The drug should be used at the highest dose the client can tolerate. D. The drug should be used for as short a time as possible.
D. The drug should be used for as short a time as possible. Rationale: Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects. Daily blood work is not necessary and the client does not need to stop other drugs prior to using corticosteroids.
A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug? A. "I have this ringing in my ears that just won't go away." B. "I feel so foggy in the mornings and it takes me so long to wake up." C. "When I eat a meal that's high in fat, I get really nauseous." D. "I seem to have lost my appetite, which is unusual for me."
A. "I have this ringing in my ears that just won't go away." Rationale: Tinnitus is associated with salicylate therapy.
A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the BEST response by the nurse? A. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B. "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." C. "OA originates with an infection. RA is a result of your body's cells attacking one another." D. "OA is associated with impaired immune function; RA is a consequence of physical damage."
A. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Rationale: OA is a degenerative arthritis with noninflammatory etiology, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints, with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. The diseases are not distinguished by the joints affected and neither has an infection etiology.
A client with exacerbation of SLE has been hospitalized on a medical unit. The nurse observes that the client expresses anger and irritation when the call bell isn't answered immediately. Which response would be the MOST appropriate? A. "You seem like you're feeling angry. Is that something that we could talk about?" B. "Try to remember that stress can make your symptoms worse." C. "Would you like to talk about the problem with the nursing supervisor?" D. "I can see you're angry. I'll come back when you've calmed down."
A. "You seem like you're feeling angry. Is that something that we could talk about." Rationale: The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care, as well as sensitivity to the psychological reactions of the client. Offering to listen to the client express anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down does not acknowledge the client's feelings. Ignoring the client's feeling suggests that the nurse has no interest in what the client has said. Offering to get the nursing supervisor also does not acknowledge the client's feelings.
A client is receiving treatment for a new diagnosis of chronic lymphocytic leukemia (CLL). Based on known risk factors, age, ethnicity, and accompanying clinical conditions, which client is MOST likely to have this disease? A. 82-year-old Vietnam War veteran with widely disseminated shingles. B. 62-year-old client of Asian descent with a left fractured hip. C. 69-year-old Gulf War veteran with DVT D. 85-year-old client of Native American/First Nation descent with chest pain.
A. 82-year-old Vietnam War veteran with widely disseminated shingles. Rationale: CLL is a common malignancy of older adults with an average age of 71 at diagnosis and the most prevalent leukemia is the Western World. It is rarely seen in clients of Native America/First Nation descent and has an infrequent incidence in clients of Asian descent. Veterans of the Vietnam War who were exposed to the herbicide Agent Orange are at risk for CLL. The time period of exposure was from 1962 to 1975 so veterans from the Gulf War in 1991 were not exposed. Infections are common with advanced CLL. None of the other conditions are related to infection, so they are not the best choice. Viral infections such as herpes zoster (shingles) can be widely disseminated with CLL.
An adult client with leukemia will soon begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy? A. Administer an antiemetic B. Administer an antimetabolite C. Administer a tumor antibiotic D. Administer an anticoagulant
A. Administer an antiemetic Rationale: Antiemetics are used to treat nausea and vomiting, the most common adverse effects of chemotherapy.
A client has a diagnosis of rheumatoid arthritis, and the primary provider has now prescribed cyclophosphamide. The nurse's subsequent assessments should address which potential adverse effect? A. Bone marrow suppression B. Acute confusion C. Sedation D. Malignant hyperthermia
A. Bone marrow suppression Rationale: When administering immunosuppressives such as cyclophosphamide, the nurse should be alert to manifestations of bone marrow suppression and infection. Confusion and sedation are atypical adverse effects. Malignant hyperthermia is a surgical complication and not a possible adverse effect.
A client with leukemia has developed stomatitis and is experiencing a nutritional deficit. An oral anesthetic has consequently been prescribed. What health education should the nurse provide to the client? A. Chew with care to avoid inadvertently biting the tongue. B. Use the oral anesthetic 1 hour prior to meal time. C. Brush teeth before and after eating. D. Swallow slowly and deliberately.
A. Chew with care to avoid inadvertently biting the tongue. Rationale: If oral anesthetics are used, the client must be warned to chew with extreme care to avoid inadvertently biting the tongue or buccal mucosa. An oral anesthetic would be metabolized by the time the client eats if it is used 1 hour prior to meals. There is no specific need to warn the client about brushing teeth or swallowing slowly because an oral anesthetic has been used.
A nurse is caring for a client who has a diagnosis of acute myelocytic leukemia (AML). Assessment of which factor most directly addresses the most common cause of death among clients with leukemia? A. Infection status B. Nutritional status C. Electrolyte status D. Liver function
A. Infections status Rationale: Because of the lack of mature and normal granulocytes that help fight infections, clients with leukemia are prone to infections. In clients with AML, death typically occurs from INFECTION of BLEEDING. Symptoms of AML include weight loss, fever, night sweats, and fatigue, which would guide the nurse to monitor the client's nutrition and electrolytes. GI problems (nausea and vomiting) and electrolyte imbalances (hyperkalemia and hypocalcemia) may result from chemotherapy use. The liver is responsible for metabolism and metabolic detox, so monitoring liver function is important for the client who is receiving chemo. These problems may contribute to and/or result in death but are not the most common cause.
An oncology nurse recognizes a client's risk for fluid imbalance while the client is undergoing treatment for leukemia. What related assessments should the nurse include in the client's plan of care? Select all that apply. A. Monitoring the client's electrolyte levels B. Monitoring the client's hepatic function C. Measuring the client's weight on a daily basis D. Measuring and recording the client's intake and output E. Auscultating the client's lungs frequently
A. Monitoring the client's electrolyte levels C. Measuring the client's weight on a daily basis D. Measure and recording the client's intake and output E. Auscultating the client's lungs frequently Rationale: Assessments that relate to fluid balance include monitoring the client's electrolytes, auscultating the client's chest for adventitious sounds, weighing the client daily, and closely monitoring intake and output. Liver function is not directly relevant to the client's fluid status in most cases.
A client with a history of arthritis is being discharged to home after right wrist surgery, and the nurse reviews nonopioid pain relief measures. Which intervention(s) would BEST address the needs of this client? Select all that apply. A. Paraffin bath B. NSAIDs C. Rolling walker D. Antiepileptic medications E. Splint or brace
A. Paraffin bath B. NSAIDs E. Splint or brace Rationale: Heat application helps relieve pain, stiffness, and muscle spasms. Paraffin baths (dips), which offer concentrated heat, are helpful to clients with wrist and small-joint involvement. Useful medications to control inflammation include NSAIDs and salicylates. Devices such as braces and splints ease pain by limiting movement.
A client with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the client's care plan? A. Protective isolation and vigilant use of standard precautions. B. Provision of a high-calorie, low-texture diet and appropriate oral hygiene. C. Including the family in planning the client's ADLs. D. Monitoring and treating the clients pain.
A. Protective isolation and vigilant use of standard precautions. Rationale: Induction therapy causes neutropenia and a severe risk of infection. This risk must be addressed directly in order to ensure the client's survival. For this reason, infection control would be prioritized over nutritional interventions, family care, and pain, even though each of these are important aspects of nursing care.
A 16-year-old female client has post chemotherapy alopecia. This prompts the nursing diagnosis of Disturbed body image and situational low self-esteem. Which response by the client would best indicate improved coping related to these diagnoses? A. Requests that her family bring her makeup and a wig B. Begins to discuss the future with her family C. Reports less disruption from pain and discomfort D. Cries openly when discussing her disease.
A. Requests that her family bring her makeup and a wig Rationale: Requesting her wig and makeup indicates that the client with alopecia is becoming interested in looking her best and that her body image and self-esteem may be improving. The other options may indicate that other nursing goals are being met, but they do not necessarily indicate improved body image and self-esteem.
A client's decrease mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. The client has been diagnosed with which health problem? A. Rheumatoid Arthritis (RA) B. Systemic lupus erythematosus (SLE) C. Osteoporosis D. Polymyositis
A. Rheumatoid Arthritis (RA) Rationale: In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately for pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not involve pannus formation.
A nurse is caring for a 78-year-old client with a history of OA. When planning the client's care, what goal should the nurse prioritize? A. The client will express satisfaction with the ability to perform ADLs B. The client will recover from OA within 6 months C. The client will adhere to the prescribed plan of care D. The client will deny signs or symptoms of OA
A. The client will express satisfaction with the ability to perform ADLs Rationale: Pain management and optimal functional ability are major goals of nursing interventions for OA. Cure is not a possibility and it is unrealistic to expect a complete absence of signs and symptoms.
An oncology nurse is providing health education for a client who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all the different subtypes of leukemia? A. The different leukemias all involved unregulated proliferation of white blood cells. B. The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function. C. The different leukemias all result in a decrease in the production of white blood cells. D. The different leukemias all involve the development of cancer in the lymphatic system.
A. The different leukemias all involve unregulated proliferation of white blood cells. Rationale: Leukemia commonly involves unregulated proliferation of WBCs. Decreased production of WBCs is associated with leukopenia. The leukemias are not characterized by their involvement with the lymphatic system.
A 60-year-old client with chronic myeloid leukemia (CML) will be treated in the home setting, and the nurse is preparing appropriate health education., Which topic should the nurse emphasize? A. The importance of adhering to the prescribed drug regimen. B. The need to ensure that vaccinations are up to date. C. The importance of daily physical activity. D. The need to avoid shellfish and raw foods.
A. The importance of adhering to the prescribed drug regimen. Rationale: Nurses need to understand that the effectiveness of the drugs used to treat CML is based on the ability of the client to adhere to the medication regimen as prescribed. Adherence is often incomplete, thus this must be a focus of health education. Vaccinations normally would not be given during treatment, and daily physical activity may be impossible for the client. Dietary restrictions are not normally necessary.
