Part Four: Palliation of Symptoms

Chapter 31 Medication Management 1. A patient who received chemotherapy 7 days ago presents to the emergency department (ED) with a fever of 102°F and chills. His absolute neutrophil count is 500 cells/μL. His spouse asks the nurse why he is being admitted to the hospital since he "doesn't look that sick". The nurse explains that which one of the following is true? A. The patientʼs fever might be an early sign of infection. B. The patient is dehydrated and requires IV hydration. C. The patient needs a platelet transfusion. D. fever might be a sign of an allergic drug reaction.

1. Answer: A Rationale: Fever may be the earliest and/or only warning sign of infection in a neutropenic patient. Patients with a single oral temperature of 38.3°C 101°F should be considered to have an infection. The nurse should anticipate orders to obtain cultures and initiate empiric antimicrobial therapy.

32 Complimentary and Alternative Modalities 1. Which one of the following classes describes the entire domain of therapies that are independent of conventional medicine? A. Integrative B. Complementary and alternative C. Allopathic D. Mind body

1. Answer: B Rationale: Complementary and alternative medicine, or CAM, describes the entire domain of therapies that fall outside of conventional medicine. Integrative therapy combines conventional treatment with evidence-based complementary therapy, but integrative therapy is not the domain. Allopathic therapy enhances conventional therapy but is not the domain. Mind body is a complementary therapy but is not the domain.

10. A patient is prescribed corticosteroids for the treatment of multiple myeloma. The nurse caring for the patient knows to monitor for which one of the following? A. Signs of bleeding B. Renal and hepatic failure C. Nausea and vomiting D. Muscle weakness

10. Answer: D Rationale: Corticosteroids can cause muscle weakness/wasting. The oncology nurse should monitor the patient with cancer's muscle strength, encourage regular exercise, and implement safety measures to prevent fall or injury. Other side effects include hyperglycemia, hypernatremia, hypokalemia, and hypocalcemia, leading to edema, hypertension, diabetes, and osteoporosis.

10. Which one of the following descriptions defines the manipulative and body-based practice of acupressure? A. the use of vigorous massage to stimulate flow of lymphatic fluid. B. the use of manual pressure and strokes on muscle tissue. C. an ancient Oriental technique associated with traditional Chinese medicine (TCM), used to restore or promote health and well-being using fine-gauge needles inserted into specific points on the body to stimulate or disperse the flow of energy. D. the use of finger or hand pressure over specific points on the body to relieve symptoms or to influence specific organ function.

10. Answer: D Rationale: The manipulative and body-based practice of acupressure is defined as the use of finger or hand pressure over specific points on the body to relieve symptoms or to influence specific organ function. Acupuncture is an ancient Oriental technique associated with traditional Chinese medicine (TCM), used to restore or promote health and well-being using fine-gauge needles inserted into specific points on the body to stimulate or disperse the flow of energy. The use of manual pressure and strokes on muscle tissue is the definition of massage. Conflicting evidence currently exists as to the effectiveness of massage therapy in patients with cancer. The use of vigorous massage to stimulate flow of lymphatic fluid is the definition of lymphatic therapy.

11. Ondansetron and granisetron disrupt signaling pathways by targeting which neurotransmitter? A. Serotonin B. Dopamine C. Histamine D. Neurokinin

11. Answer: A Rationale: Ondansetron and granisetron are 5-HT3 antagonists, blocking the action of serotonin along nerve pathways. Dopamine is a D2 antagonist. Histamine is a H1 antagonist. Neurokinin is an NK1 antagonist.

11. Which one of the following is a safety issue when using aromatherapy? A. Standardization is lacking in the preparation and clinical use of essential oils. B. Use of aromatherapy can trigger depression, and these agents can target psychological well-being. C. Agents have a narrow range of safe applicability. D. Patients frequently develop an allergy to the transporter.

11. Answer: A Rationale: There are currently no standards of practice or processing regulations for aromatherapy since essential oils have a wide range of quality levels. Aromatherapy targets physical imbalances, as well as psychological and spiritual issues. Although individuals can develop an allergy to the transporting vehicle, allergies are not a major safety concern.

12. During a follow-up visit, a patient reports that she is experiencing breakthrough chemotherapy-induced nausea and vomiting despite receiving palonosetron 0.25 mg PO prior to her chemotherapy infusion. The nurse should anticipate administering which one of the following antiemetics? A. Ondansteron 8 mg IV B. Dexamethasone 12 mg IV C. Granisetron 2 mg PO D. Repeat dose of palonosetron

12. Answer: B Rationale: The general principle of breakthrough chemotherapy-induced nausea and vomiting (CINV) treatment is to introduce one agent from a different drug class to the current regimen. If palonosetron is given prior to chemotherapy, the use of another 5HT3 antagonist is not warranted for the management of breakthrough CINV.

12. The term Feldenkrais refers to which one of the following? A. Gentle manipulation of the skull to reestablish natural configuration and movement. B. The use of vigorous massage to stimulate the flow of lymphatic fluid out of an area of the body. C. A somatic education system that teaches movement and gentle manipulation to increase body awareness and function. D. A technique that uses movement and touch to restore balance to the body.

12. Answer: C Rationale: Feldenkrais refers to a method that teaches movement and manipulation to increase body awareness. Gentle manipulation of the skull to reestablish natural configuration and movement is the definition for cranial osteopathy. Lymphatic therapy is the use of vigorous massage to stimulate flow of lymphatic fluid. The technique that uses movement and touch to restore balance to the body is called the Alexander technique and is not a part of the Feldenkrais method.

13. Metoclopramide has a black box warning for which adverse reaction? A. Drug-drug interactions B. Prolongation of QT interval C. Extrapyramidal symptoms D. Orthostatic hypotension

13. Answer: B Rationale: Metoclopramide has a black box warning for sudden death related to prolonged QT intervals. This medication should not be administered if QTc is > 500 msec. If the patient experiences shortness of breath or palpitations while receiving this medication, they should immediately notify their healthcare provider. Extrapyramidal side effects may occur.

13. Which one of the following terms defines reiki? A. A technique for balancing the flow of energy in the body through the transfer of human energy. B. An energy healing technique that uses nursing process and specific protocols. C. The use of magnetic fields to positively impact the body to stimulate healing. D. An energy healing modality in which the practitioner directs the flow of energy to various parts of the body to facilitate healing and relaxation.

13. Answer: D Rationale: In Reiki, the practitioner directs the flow of energy by placement of the hands on the body in specific patterns (without applying deep pressure) to redirect or restore energy flow. Therapeutic touch is described in A, while B refers to healing touch, and C describes magnetic therapy.

14. The nurse understands which one of the following is an essential principle of analgesic medication management? A. For chronic pain, patients should have long-acting and breakthrough options available. B. Patients with acute pain should avoid opioids to prevent physical dependence. C. Opioid tolerance means the patient has developed a psychological addiction to the drug. D. Stool softeners should only be administered once the patient reports changes in bowel movements.

14. Answer: A Rationale: Chronic pain lasts longer than three months and can be a source of background pain for patients with cancer. Chronic pain is commonly associated with breakthrough pain. Analgesic medication management should be prescribed to provide pain control for a 24-hour period. If opioids are used, patients should have long-acting and breakthrough options available when pain is constant. Prophylaxis for constipation with a stool softener and bowel stimulant should be considered for all patients who are started on opioid analgesics, and the regimen should be optimized to assure regular bowel movements. Tolerance occurs in patients who take opioids regularly; that is, they require higher doses to achieve the same amount of analgesia.

14. Acupuncture is often successful in alleviating pain because of which one of the following? A. Acupuncture is often successful in alleviating pain because of the placebo effect in which patients expect pain relief and, therefore, feel less pain. B. Acupuncture is often successful in alleviating pain because the introduction of pain at the insertion site allows the patient to refocus his or her perception of the original site of pain. C. Acupuncture is often successful in alleviating pain because the stimulation of the nerve fibers entering the dorsal horn of the spinal cord, which mediates the impulses of the other parts of the body, and allows the patient to experience less at pain at the original site. D. Acupuncture is often successful in alleviating pain because the pressure applied by exerting a finger and thumb on the specific point on the surface of the skin acts as an entrance and an exit for an internal healing force, thereby eliminating the overall sensation of pain.

14. Answer: C Rationale: Acupuncture needles applied in one part of the body can affect the pain sensation in another part of the body when impulses stimulate the nerve fibers in the dorsal horn of the spinal cord. Acupuncture treatments could create a placebo effect and could help patients to refocus their concentration, but these are not the primary actions of the therapy. Acupressure, not acupuncture, uses pressure applied to skin surface with the finger and thumb. Acupressure is similar to acupuncture, but without the needles.

15. S. L. is a 48-year-old male patient who arrives to the clinic with complaints of nausea, sweating, and insomnia. During the medication reconciliation, he states that he recently stopped taking his prescribed morphine sulfate. The nurse suspects he is experiencing which one of the following? A. poor pain control B. constipation C. addiction D. withdrawal

15. Answer: D Rationale: Abrupt discontinuation of opioids can lead to withdrawal. Symptoms of withdrawal include nausea, vomiting, perspiration, chills, tachycardia, anxiety, and insomnia. Addiction is a psychological sign where the patient craves the drug despite knowing the harm. An assessment for pain and GI is needed to determine adequate pain control and monitor for signs of constipation.

16. Which one of the following medications would be appropriate for a patient experiencing somnolence from opioid use? A. Methyphenidate B. Metoclopramide C. Micafungin D. Mithramycin

16. Answer: A Rationale: Methylphenidate (Ritalin) may be helpful for somnolence or mental clouding from opioids. Metoclopramide is used as an antiemetic. Micafungin is an antifungal agent. Mithramycin is a chemotherapy agent.

17. A patient with cancer has just been prescribed oral oxycodone. The nurse caring for the patient knows that teaching for the patient will include which one of the following? A. avoid grapefruit juice. B. take medication with food. C. take medication on an empty stomach. D. medication should be taken in combination with acetaminophen.

17. Answer: B Rationale: Opioids can cause nausea and vomiting. Patients should be taught to take medication with food to prevent GI upset.

18. Anxiolytics can be used as supportive treatment for patients with cancer to do which one of the following? A. prevent or manage anticipatory nausea. B. replace the need for narcotic pain control. C. prevent opportunistic infection. D. treat clinical depression.

18. Answer: A Rationale: Anxiolytics can be used to reduce anxiety associated with diagnosis and treatment of cancer, to manage anticipatory nausea, reduce pain associated with anxiety, and manage alcohol or narcotic withdrawal.

19. A patient has just been prescribed Lexapro 10 mg to manage depression. Which one of the following statements would most likely indicate that the patient needs additional teaching? A. "I should take this medication with food." B. "If I experience any side effects, I will discontinue and follow up at my next appointment." C. "I will carry a bottle of water with me to help relieve dry mouth." D. "My mood should be better by the end of the week."

19. Answer: D Rationale: Lexapro is an SSRI. Effects may not be seen for the first 2-4 weeks. To prevent withdrawal, patients should slowly taper off the medication should they experience side effects.

2. Which one of the following antimicrobial agents is appropriate for the treatment of cytomegalovirus (CMV)? A. Ganciclovir B. Levofloxacin C. Acyclovir D. Fluconazole

2. Answer: A Rationale: Ganciclovir is an anti-viral agent that provides coverage for CMV treatment. Levofloxacin and fluconazole do not provide coverage against viruses. Acyclovir is indicated for herpes simplex virus (HSV) and varicella zoster (VZV), not CMV. Valganciclovir is preemptive therapy for CMV.

2. The two broad subgroups of complementary health approaches defined by National Center for Complementary and Integrative Health (NCCIH) are which one of the following? A. massage and acupuncture. B. Tai chi and healing touch. C. chiropractic and osteopathic manipulation. D. natural products and mind and body practices.

2. Answer: D Rationale: Natural products as well as mind and body practices are the two subgroups defined by the National Center for Complementary and Integrative Health (NCCIH). Massage and acupuncture are therapies within the mind and body group. Tai chi and healing touch are therapies within the mind and body group. Chiropractic and osteopathic manipulation are therapies within the mind and body group.

20. Which one of the following medications is an appropriate option for managing sleeping disorders? A. Linezolid B. Posaconazole C. Zolpidem D. Temozolomide

20. Answer: C Rationale: Zolpidem (Ambien) is a non-benzodiazepine receptor agonist indicated for sleep latency and mid-night awakenings. Linezolid is used to treat gram-positive bacterial infections. Posaconazole is used to treat fungal infections. Temozolomide is a chemotherapy agent.

21. A cancer patient who has been diagnosed with a major depressive disorder has recently been prescribed an antidepressant. Which one of the following is the most important question to ask during the patient's follow up appointment? A. "Is your pain being well controlled?" B. "Are you having any thoughts of harming yourself?" C. "How would you describe your sleep pattern over the last few nights?" D. "Did you drive yourself to clinic today?"

21. Answer: B Rationale: Antidepressant therapeutic effect can take up to 3 weeks. Patients with major depressive disorder may have suicidal thoughts and should be routinely screened for suicidal ideation or emotional changes until a therapeutic response is achieved. Responses A and C are appropriate assessment questions, but suicide prevention is an important safety issue.

22. Which one of the following antidepressants is associated with a higher risk of anticholinergic effects (blurred vision, dry mouth, and constipation)? A. Fluoxetine B. Sertraline C. Citalopram D. Amitriptyline

22. Answer: D Rationale: Tricyclic antidepressants (TCAs) are associated with anticholinergic effects and have a 4 toxicity comparison. Fluoxetine, sertraline, and citalopram are SSRIs and do not have anticholinergic toxicities.

23. Which one of the following chemotherapy drugs has the potential to lower the seizure threshold? A. Cytarabine B. Melphalan C. Carmustine D. Mitoxantrone

23. Answer: C Rationale: Carmustine is a chemotherapy drug which has the potential to lower seizure threshold.

24. Levetiracetam is associated with which one of the following side effects? A. Somnolence B. Hepatotoxicity C. Nausea D. Hallucinations

24. Answer: A Rationale: Somnolence is a side effect associated with levetiracetam. The agent may also be associated with dizziness and rash and occasionally psychosis.

25. Anticonvulsants have the potential to change drug metabolism and drug-drug interactions through which mechanism of action? because they are categorized as which one of the following types of enzymes? A. Inducers B. Substrates C. Inhibitors D. Receptors

25. Answer: A Rationale: Anticonvulsants are enzyme inducers, which causes an increase in metabolism and decreased exposure to the medication. Enzyme inhibitors decrease metabolism, causing exposure of the medication to be increased. A substrate for an enzyme is vulnerable to changes in enzyme activity. If an oncology nurse has concerns about drug-drug interactions while caring for a patient, consider consulting with a pharmacist.

26. T.W.is a 60-year-old male patient who has received an autologous stem cell transplant 5 days ago and has an order for filgrastim. The nurse caring for him understands this medication is used to do which one of the following? A. Filgrastim is used to prevent veno-occlusive disease. B. Filgrastim is used to support neutrophil engraftment. C. Filgrastim is used to reduce the need for red blood cell transfusions. D. Filgrastim is used to prevent delayed nausea and vomiting.

26. Answer: B Rationale: Filgrastim is a myeloid growth factor used after autologous stem cell transplant and cord blood transplantation to support neutrophil engraftment.

27. Myeloid growth factors are used to stimulate production of which one of the following? A. neutrophils and macrophages B. natural killer cells C. B lymphocytes D. plasma cells

27. Answer: A Rationale: Myeloid growth factors stimulate the proliferation and maturity of neutrophils and macrophages.

28. Erythropoietin can increase the risk of which adverse event? A. Bone pain B. Deep vein thrombosis C. Splenic rupture D. Peripheral neuropathy

28. Answer: B Rationale: The oncology nurse should understand the increased risk for thrombotic events when administering erythropoietin. Patients and their families should be taught to monitor for signs of swelling or redness in the lower extremities and to notify their provider should this occur.

29. In the neutropenic patient with cancer, which one of the following surgeries may impact the treatment of active infections? A. Lobectomy B. Appendectomy C. Splenectomy D. Cholecystectomy

29. Answer: C Rationale: Splenectomy and functional asplenia may increase the risk of infection where antimicrobials would be warranted. A lobectomy is a surgery to remove one of the lobes of the lungs; an appendectomy removes the appendix and a cholecystectomy is surgery to remove the gallbladder. These surgeries do not impact immune suppression.

3. Patients who are considered high risk for febrile neutropenia should avoid which one of the following medications? A. Antipyretics B. Antibiotics C. Antivirals D. Antifungals

3. Answer: A Rationale: Fever is often the first and only sign of infection in neutropenic patients. Antipyretics, including acetaminophen, aspirin, and non-steroidal anti-inflammatory agents, should be avoided in high-risk individuals as they may mask fever.

3. When an oncology nurse is discussing safety and risks with a patient, which of the following factors is true regarding herbal and botanical medicine? A. United States Food and Drug Administration (FDA) approved B. Tightly regulated in the United States C. Efficacy ensured D. Interacts with prescribed medication

3. Answer: D Rationale: Herbal and botanical medicine can interact with prescribed medication. Herbal/botanical medicine can pose significant risks to the patient due to interactions with conventionally prescribed medications. Herbal/botanical medicine is not FDA approved and is not well-regulated in the U.S. as in other countries. Herbal/botanical medicine safety and efficacy is not guaranteed.

30. S. R. is a 62-year-old male patient with cancer is experiencing anxiety. The nurse caring for him relays the patient assessment to the physician who orders a serotonin selective reuptake inhibitors (SSRI) to begin while the patient remains hospitalized. The nurse would understand that SSRI do which one of the following? A. relieves anxiety symptoms early in therapy B. have an optimal effect when starting at the maximum dose and then taper down and then decreased to optimal dose for each unique patient C. effect will be seen in first seven days D. abrupt discontinuation may precipitate withdrawal syndrome

30. Answer: D Rationale: Serotonin selective reuptake inhibitors (SSRI) may induce anxiety symptoms, not relieve them, early in therapy. SSRIs are started at a low dose, not a high dose, and then increased to an optimal dose. The effect of SSRIs may not be seen for the first 2-4 weeks. Abrupt discontinuation may precipitate withdrawal syndromes.

31. A patient with cancer is diagnosed with major depressive disorder which is characterized by which one of the following? A. sad, empty and irritable mood occurring late in the day. B. higher use of healthcare services. C. occurs in about 75% of patients with cancer. D. depressive symptoms occur daily for at least 5 days.

31. Answer: B Rationale: Major depressive disorder is characterized by depressive symptoms lasting most of the day, every day, for at least 2 weeks. Major depressive disorder occurs in about 25% of patients with cancer, leading to poor quality of life and functional status, higher use of healthcare services, and non-adherence with treatment.

32. Which one of the following types of antidepressants would the patient with cancer be counseled to make dietary modifications to avoid tyramine? A. Serotonin selective reuptake inhibitors (SSRIs) B. Serotonin and norepinephrine reuptake inhibitors (SNRIs) C. Tricyclic antidepressants (TCA) D. Monoamine oxidase inhibitors (MAOIs)

32. Answer D Rationale: Dietary modifications to avoid tyramine are critical for patients on monoamine oxidase inhibitors (MAOIs). Tyramine does not impact serotonin selective reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs).

33. S. R. is the 62-year-old male patient with cancer who was diagnosed with depression. He was recently started on an antidepressant. If improvement in symptoms occur, which one of the following is true about the therapy? A. The therapy should be continued for six months. B. The therapy should be continued for six weeks. C. The therapy should be discontinued. D. The patient should begin gradual tapering until off medication.

33. Answer: A Rationale: Therapy should continue for 6 months following improvement in symptoms to avoid relapse of depression. Taking antidepressants as scheduled and allowing the time necessary for a therapeutic response to the medications is required. There is a potential for withdrawal effects with abrupt cessation; therefore, gradually taper of dose should occur at discontinuation.

34. When applying the principles of medical management with myeloid growth factors (MGFs), the risk of neutropenia is increased in which one of the following patient populations? A. patients with endocrine dysfunction B. patients with recent surgery or open wounds C. pediatric patients D. patients with pulmonary hypertension

34. Answer: B Rationale: Risk is increased in select patients including: recent surgery or open wounds, prior chemotherapy or radiation therapy, persistent neutropenia, bone marrow involvement of the tumor, liver dysfunction, renal dysfunction, and age greater than 56 years.

35. When evaluating the patient with cancer's iron stores prior to use of erythropoiesis-stimulating agents (ESA) or erythropoetin (EPO), such as epoetin alfa, epoetin alfa-epbx, and darbpoetin, the oncology nurse should consider which one of the following statements? A. patients who are iron-deficient will respond best to EPO. B. this medication is warranted in patients with hemoglobin greater than 16 g/dL. C. the increased risk of venous thromboembolism. D. the increased number of RBC transfusions to treat anemia.

35. Answer: C Rationale: EPO is associated with an increased risk of venous thromboembolism. Patients who are iron-deficient will not respond to EPO. EPO should not be given in patients with hemoglobin greater than 10 g/dL. EPO decreases, not increases, the number of RBC transfusions required to treat anemia.

36. When performing the medication reconciliation for the neutropenic patient, the oncology nurse would expect the cell nadir to occur during which one of the following? A. The cell nadir would occur the day after the last chemotherapy dose. B. The cell nadir would occur at the beginning of the third chemotherapy cycle. C. The cell nadir would occur when the absolute neutrophil count is greater than 500/mm3. D. The cell nadir would occur in 7-14 days after chemotherapy treatment.

36. Answer: D Rationale: The cell nadir occurs 7 to 14 days after the chemotherapy treatment. Neutropenia occurs when the absolute neutrophil count (ANC) is less than 500/mm3.

37. The potential for "Disturbed Body Image" would be important for the oncology nurse to assess and document with which one of the following drug classification? A. Corticosteroids B. NSAIDS: Cox-2 selective agent C. Salicylates D. Aminoglycosides

37. Answer: A Rationale: Central obesity, moon face, buffalo hump, easy bruising, acne, hirsutism, striae, and skin atrophy occur with use of corticosteroids and would warrant the assessment of the patient's body image and concerns. The oncology nurse should provide the opportunity for the patient with cancer to share concerns and discuss coping strategies, and educate the patient regarding care of skin and safety precautions. NSAIDS: Cox-2 selective agent, salicylates, and aminoglycosides do not cause the degree, if any, body image concerns.

38. When requesting a prescription from the provider for Morphine to control pain, the oncology nurse should consider which one of the following? A. Morphine 30 mg IV has equivalent potency as Morphine 10 mg oral B. Onset of effect for oral Morphine is 30 minutes C. Peak effect is 60 minutes with Morphine IV D. Morphine IV and oral have a duration of effect of 4-8 hours

38. Answer: B Rationale: The onset of effect for oral Morphine is 30 minutes and Morphine IV is 5-10 minutes. Morphine 10 mg IV has equivalent potency as Morphine 30 mg orally. The peak effect is 10-15 minutes with Morphine IV and 60 minutes for Morphine oral. Morphine IV and oral both have a duration of effect of 3-4 hours.

39. Temperature threshold for neutropenic patients is defined as which one of the following? A. Multiple axillary temperatures over 37.5°C (99.5°F) B. Two consecutive rectal temps over 36.8°C (98.2°F) C. Single oral temperature of 38.3°C (101°F) D. Sustained temperature of 38°C (100.4°F) over three hours.

39. Answer: C Rationale: For accurate results, axillary temperature should be avoided. Rectal temperatures should be avoided to prevent potential injury to the rectal mucosa. Temperature threshold for the neutropenic patient should be defined as a sustained oral temperature of 38°C (100.4°F) over 1 hour or a single oral temperature of 38.3°C (101°F).

4. Art and music therapy are modalities labeled as which one of the following? A. mind body B. whole medicine C. biologically based D. manipulative

4. Answer: A Rationale: Mind body modalities include art and color therapy, music therapy, guided imagery, meditation, yoga, and T'ai chi. Whole medical systems are therapeutic approaches that include chiropractic medicine, homeopathic, and osteopathic medicine. Biologically based therapies use substances found in nature to promote wellness and treat illness, such as biofeedback, hydrotherapy, and energy work. Manipulative and body-based practices include acupuncture, acupressure, dance therapy, and traditional Chinese medicine.

4. Which one of the following statements regarding vancomycin as an empiric therapy is true? A. Dose adjustments per pharmacy are not required prior to initiation. B. Vancomycin provides appropriate empiric coverage of gram-negative bacteria. C. Empiric vancomycin is recommended for low-risk patients. D. Routine use of empiric vancomycin should be avoided.

4. Answer: D Rationale: Vancomycin should not be routinely included in empiric therapy, except in select clinical situations. The routine use of vancomycin can lead to the occurrence of vancomycin-resistant organisms (VRE). Vancomycin is indicated for gram-positive bacterial coverage, and dose adjustments are required to prevent renal toxicity.

40. A patient with lymphoma, who is currently receiving chemotherapy, presents to the urgent clinic complaining of fever and aching for past 36 hours. The patient has a central line with no redness, tenderness or edema at the insertion site. Skin is warm and intact. The patient is tolerating oral fluids without nausea or vomiting. The physician orders blood cultures. When obtaining the blood cultures, the gold standard for diagnosis is to draw which one of the following? A. two peripheral cultures B. two central line cultures C. no cultures until 48 hours for duration of symptoms D. one peripheral and one from the central line

40. Answer: D Rationale: The gold standard for diagnosis in this patient population is to draw one set peripherally and one from central lines when the patient has a central venous catheter. Two peripheral cultures should be drawn if no central venous catheter is in place. Cultures would be obtained before 48 hours, so medication can be administered for symptom relief.

41. In a low-risk patient with febrile neutropenia, the provider may prescribe viral prophylaxis in patients with which one of the following prior conditions? A. herpes simplex virus (HSV) B. human immunodeficiency virus (HIV) C. pseudomonas D. respiratory syncytial virus (RSV)

41. Answer: A Rationale: Pseudomonas infections are diseases caused by a bacterium from the genus Pseudomonas which is found widely in the environment, such as in soil, water, and plants; this is not a virus. Human immunodeficiency virus (HIV) and respiratory syncytial virus (RSV) are viruses, but only herpes simplex virus (HSV) would routinely warrant antimicrobial prophylaxis.

42. During which one of the following time frames would the nurse anticipate discontinuation of antimicrobial therapy for the resolution of a fever in a low risk patient that is clinically stable with negative cultures but with an ANC remaining less than 500? A. after a total of 14 days B. after a total of 5 to 7 days C. after a total of 17 to 21 days D. after the ANC is above 500 for 7 consecutive days

42. Answer: B Rationale: In low-risk patients that are clinically stable with negative cultures and an ANC remaining less than 500, consider discontinuation of antibiotics after a total of 5 to 7 days. Continuing beyond this amount of time may unnecessarily cause additional antimicrobial side effects.

43. Stevens-Johnson syndrome is an adverse effect of antimicrobial therapy impacting which one of the following areas? A. hepatic B. cardiovascular C. gastrointestinal D. dermatologic

43. Answer: D Rationale: Stevens-Johnson syndrome is a severe skin reaction with one of the primary symptoms being the presence of blisters. The infection can spread to the mucous membranes which could cause blisters to form inside the body, making eating and drinking painful. If left untreated, Stevens-Johnson syndrome can spread to other organs. The impact is on dermatologic area, and not the liver, heart, or gastrointestinal.

44. A patient who is on a chemotherapy regimen is requesting the measles, mumps, and rubella (MMR) vaccine since her grandchildren have been exposed to measles in school. If the provider warrants this as necessary, the vaccine should be administered: A. more than 2 weeks prior to chemotherapy. B. one month after the chemotherapy regimen completed. C. greater that 4 weeks prior to chemotherapy. D. at the next chemotherapy appointment since it is not a live virus.

44. Answer: C Rationale: Live virus vaccines use the weakened (attenuated) form of the virus. The measles, mumps, and rubella (MMR) vaccine and the varicella (chickenpox) vaccine are examples. Inactivated vaccines may be administered > 2 weeks prior to chemotherapy; live virus vaccines should be given > 4 weeks prior to chemotherapy.

45. Which one of the following may be used as a means of timing vaccine administration in a patient that is post-transplant? A. human leukocyte antigen-DR B. CD34 C. vascular endothelial growth factor receptor (VEGFR) D. complete blood count (CBC)

45. Answer: B Rationale: CD34 is the most commonly used marker for hematopoietic stem/progenitor cells in clinical hematology. Clinicians even use this marker as a quality criterion for the hematopoietic graft. Human leukocyte antigen-DR and vascular endothelial growth factor receptor (VEGFR) are associated markers. A complete blood count (CBC) would not be used alone for timing vaccines.

46. F. L. is a 75-year-old patient who presents in the cancer center with a history of renal insufficiency and cardiovascular disease and is complaining of musculoskeletal pain. The medication list also reveals the patient is prescribed coumadin. When prescribing a medication for the patient's pain, which one of the following would put the patient be at high risk for toxicity? A. NSAIDs B. anti-convulsants C. acetaminophen D. corticosteroids

46. Answer: A Rationale: Patients at risk for toxicities with NSAIDs are age 65 or older, history of GI ulcers, renal insufficiency, cardiovascular disease, concurrent aspirin or anticoagulant use, and history of ulcerative colitis. Anti-convulsants, acetaminophen, or corticosteroids would be less toxic with the history presented.

47. Which one of the following describes the use of Cannabis for chemotherapy-induced nausea and vomiting? A. Cannabis is used as an agent for highly emetogenic intravenous chemotherapy. B. Cannabis is legal in every state for medical use only with chemotherapy. C. Cannabis is not prescribed due to prolonged, irreversible side effects. D. Cannabis is used as an agent for breakthrough nausea and vomiting.

47. Answer: D Rationale: Highly emetogenic intravenous chemotherapy would warrant medications such as NK1 RA 5-HT3 RA dexamethasone prior to chemotherapy followed by NK1 RA (if needed) and dexamethasone. Agents for breakthrough nausea and vomiting include cannabis (medical marijuana) in addition to dopamine antagonists such as prochlorperazine, droperidol, promethazine, dexamethasone, lorazepam, ondansetron, metoclopramide, and cannabinoids such as dronabinol and nabilone. Legalization of marijuana for medical use is growing in a number of states, but not legal in every state. Cannabis may have long- and short-term side effects, but may still be prescribed for breakthrough nausea and vomiting.

48. Fat-to lean body ratio is important to assess when prescribing pain medication by which one of the following routes? A. buccal B. transdermal C. subcutaneous D. rectal

48. Answer: B Rationale: Absorption and onset of pain medications vary with patients with any route including buccal, rectal, and subcutaneous. Fat-to-lean body ratio impacts transdermal preparations and is not recommended in cachectic patients and takes a longer time to onset in obese patients. 49. Answer: ARationale: Amphotericin B and fluconazole are antifungals that are indicated for a fungal infection such as Candida. Caspofungin (Cancidas) is an antifungal, but ciprofloxacin is an antimicrobial for gram-negative bacteria. Voriconazole (Vfend) is used for Candida infection, but imipenem is for gram-positive infections. Cidofovir is an antiviral agent.

49. G. H. is a 50-year-old male patient with cancer who has just been diagnosed as having a Candida infection. Which one of the following medications does his oncology nurse expect the primary practitioner to order? A. Amphotericin B or fluconazole (Diflucan) B. Caspofungin (Cancidas) or ciprofloxacin (Cipro) C. Voriconazole (Vfend) or fluconazole (Diflucan)

49. Answer: A Rationale: Amphotericin B and fluconazole are antifungals that are indicated for a fungal infection such as Candida. Caspofungin (Cancidas) is an antifungal, but ciprofloxacin is an antimicrobial for gram-negative bacteria. Voriconazole (Vfend) is used for Candida infection, but imipenem is for gram-positive infections. Cidofovir is an antiviral agent.

5. Adverse reactions associated with amphotericin B (deoxycholate) include which one of the following? A. nephrotoxicity and electrolyte wasting. B. myelosuppression and central nervous system (CNS) toxicity. C. ocular toxicity and prolonged QTc. D. serotonin syndrome and ototoxicity.

5. Answer: A Rationale: Amphotericin B adverse effects include nephrotoxicity, electrolyte wasting, and infusion reaction. Pre-hydration and pre-medications are needed to prevent complications.

5. Movement of fluid from the vascular space into the interstitial space causing edema would occur by which one of the following? A. decreased capillary pressure. B. increased capillary permeability. C. increased plasma oncotic pressure. D. lowered hydrostatic pressure.

5. Answer: B Rationale: Increased capillary permeability can occur with treatment with interleukin-2 or vascular endothelial growth factors. Increased, not decreased, capillary pressure would lead to edema when the volume of blood is expanded or with obstruction. Decreased, not increased, plasma oncotic pressure results in increased fluid in the tissues. When albumin is decreased, fluid leaks into interstitial spaces. Raised, not lowered, hydrostatic pressure drives fluid from the capillaries into the interstitial spaces.

5. Which one of the following is an appropriate response by the oncology nurse when assessing the patient's use of complementary and alternative medicine at the patient's initial appointment? A. "We only need to know the medicines prescribed by your primary physician for your medical record." B. "Complementary therapy will be assessed at the end of your treatment visit." C. "If there are cultural or religious practices that you incorporate for your health, it should be noted for your oncology team." D. "Biologically based therapies are not part of your cancer care so they do not need be addressed at this time."

5. Answer: C Rationale: Patient values and preferences, which include cultural and religious practices, are part of a comprehensive complementary and alternative medicine (CAM) assessment. Relevant clinical information is incorporated into the assessment and includes items such as comorbidities, allergies, and all medications, including CAM. A comprehensive patient assessment of CAM is done at first visit and ongoing through their cancer care. Biologically based therapies, such as biofeedback, herbal therapy, and energy work, are a part of the CAM assessment.

50. Administration for the management of acyclovir include which one of the following? A. Dosing should be based on the patient's actual body weight to ensure adequate blood levels. B. It is an effective preemptive therapy for cytomegalo-virus (CMV) in high-risk patients with cancer. C. Probenecid is given to patients to prevent renal reabsorption and related toxicities. D. Fluid hydration is necessary if therapeutic IV doses are used.

50. Answer: D Rationale: Doses are based on ideal, not actual, body weight. Ganciclovir, not acyclovir, is the antiviral regarded as being effective preemptive therapy for cytomegalovirus in high-risk patients with cancer. Probenecid is given to patients to prevent renal reabsorption of cidofovir.

51. Antiemetics that belong to the same class as Zofran affect nausea and vomiting by acting as which one of the following? A. 5 HT3 agonists B. D2 antagonists C. NK-1 antagonists D. 5 HT3 antagonists

51. Answer: D Rationale: The serotonin antagonists include ondansetron (Zofran). Prochlorperazine is a D2 antagonist. Aprepitant is an NK-1 antagonist.

52. Which one of the following statements places antiemetics with the appropriate neurotransmitter agent? A. Serotonin - aprepitant B. Cannabinoid agonist - dronabinol C. Histamine H1 antagonist - prochlorperazine D. Dopamine D2 antagonist - promethazine

52. Answer: B Rationale: Major neurotransmitter targets are as follows: serotonin (5HT3 antagonists, e.g., ondansetron), neurokinin (NK-1 antagonist, e.g., aprepitant), dopamine (D-2 antagonist, e.g., prochlorperazine), histamine (H-1 antagonist, e.g., promethazine), acetylcholine (muscarinic, e.g., scopolamine), and cannabinoid (cannabinoid agonist, e.g., dronabinol).

53. Which one of the following is true related to the onset of action for fentanyl? A. IV 2 to 3 minutes B. IV 5 to 6 minutes C. Patch 8 to 10 hours D. Buccal 15 to 30 minutes

53. Answer: B Rationale: The pharmacokinetics of fentanyl support B as the correct answer. Fentanyl patch onset is 18 to 24 hours and buccal administration is 5 to 15 minutes.

54. Which one of the following is a common side effect of concern for patients receiving serotonin reuptake inhibitors? A. Hot flashes B. Neuropathy C. Sexual dysfunction D. Increased appetite

54. Answer: C Rationale: The majority of the serotonin reuptake agents can contribute to sexual dysfunction. The other options - hot flashes, neuropathy, and increased appetite - are not expected side effects.

55. A common side effect of filgrastim (G-CSF) is which one of the following? A. sedation B. liver dysfunction C. constipation D. bone pain

55. Answer: D Rationale: Bone pain is the main side effect of filgrastim. Bone pain occurs as a result of expansion of granulocytic precursors in the patient's bone marrow. Often, a patient's peripheral white blood count will be correspondingly high. Sedation is not a side effect and the other options of liver dysfunction and constipation are not expected side effects.

6. Which one of the following chemotherapy agents is commonly impacted by natural products and would warrant a review of the patient's medication and complementary and alternative medicine (CAM) list in their electronic medical record (EMR) to ensure safety? A. Adriamycin B. Docetaxel C. Lupron D. Bleomycin

6. Answer: B Rationale: Docetaxel is noted to have interactions with allium sativum, echiacea purpurea, and hypericum perforatum. Adriamycin, Lupron, and Bleomycin are not known to have specific interactions with natural products.

6. A patient with cancer complains of burning on urination. Microbiology results show the urinalysis with leuko-esterase, white blood cell (WBC) and nitrate positivity, and it is positive for Escherichia coli. Which one of the following nursing actions would be indicated? A. Encourage patient to drink fluids in order to prevent antibiotic use. B. Ensure the patient has an order for prophylactic antibiotics upon discharge to prevent future urinary tract infections (UTIs). C. Report culture results to provider and anticipate orders for antibiotics. D. No further action is needed.

6. Answer: C Rationale: Stewardship tasks performed by the nurse includes reviewing culture results and reporting positive results to the provider in a timely manner. Overuse of antibiotics should be avoided to prevent organism resistance.

7. G. T. is a 58-year-old male who is in the clinic receiving chemotherapy for lung cancer and is inquiring about whether he can receive the flu vaccine before he leaves clinic today. The nurse caring for him responds to him with which one of the following? A. influenza vaccines contain live virus and should be avoided. B. the influenza vaccine can be administered between chemotherapy cycles. C. receiving the influenza vaccine may increase the risk for infection. D. the vaccination schedule is dependent on his CD34 counts.

7. Answer: B Rationale: Influenza is an inactivated virus and safe for patients receiving cancer treatment. Inactivated viruses can be administered two weeks prior to chemotherapy or in between cycles. CD34 markers do not need to be used as a means of timing his vaccination schedule since he is not a stem cell transplant patient.

7. Massage therapy is therapeutic to decrease emotional and physical tension, and is appropriate if which one of the following conditions is met? A. platelets <50,000. B. applied directly at the bone metastatic site. C. peripheral neuropathy grade 3 or less. D. white blood cell (WBC) count is < 1500.

7. Answer: C Rationale: Patients with peripheral neuropathy grade 3 or less may receive massage over the affected area. Massage is contraindicated in a patient diagnosed with thrombocytopenia with a platelet count of less than 50,000 due to the risk of bleeding. Patients with suspected or known bone metastasis should not receive pressure or jostling over the affected areas. Patients with severe neutropenia and WBC below 1500 should not receive massage therapy.

8. Anti-inflammatory agents are effective in treating pain and inflammation because they do which one of the following? A. block major nerve pathways and conduction. B. inhibit cyclooxygenase and prostaglandin production. C. decrease platelet function and bleeding risk. D. lower temperature threshold and signs of infection.

8. Answer: B Rationale: Anti-inflammatory agents work by decreasing the adverse effects of inflammation. Their mechanism of action inhibits cyclooxygenase which leads to decreased prostaglandin production and decreased inflammation. Anti-inflammatory agents should be avoided in individuals at risk for infection and/or neutropenia as they may mask fever which is a side effect. Another side effect is decreased platelet function and increased risk for bleeding.

8. Which one of the following descriptions defines the mind-body modality of neurolinguistic programming (NLP)? A. This modality has a meditative component that brings harmony to body, mind, and spirit. B. With this modality, the patient focuses on positive aspects of his or her life to promote a positive outlook over time. C. Practices within this modality share characteristics and often involve focused breathing and a relaxed yet alert state that promotes control over thoughts and feelings. D. This is a modality with a structured process that uses live or recorded readings describing different scenarios or detailed images to guide the patient through a certain process.

8. Answer: B Rationale: With the mind-body modality of neurolinguistic programming (NLP), the patient focuses on positive aspects of his or her life to promote a positive outlook over time. An example of this modality is having a patient record daily entries in a "gratitude journal." The entries focus on recalling positive aspects of his or her life to promote a positive outlook over time. The overriding principle behind NLP is that an individual gets more of whatever that person is focusing on. The modality that has a meditative component that brings harmony to body, mind, and spirit is yoga. Practices within the modality of meditation share characteristics and often involve focused breathing and a relaxed yet alert state that promotes control over thoughts and feelings. Guided imagery is a modality with a structured process that uses live or recorded readings describing different scenarios or detailed images to guide the patient through a certain process.

9. A patient has returned to clinic for a follow up appointment and reports that she has been taking an over-the-counter NSAID for the mild bone pain she has been experiencing. Which other reported medication should prompt the nurse to notify the medical team? A. Metoprolol B. Clopidogrel C. Multivitamin D. Ciprofloxacin

9. Answer: B Rationale: The antiplatelet effects of NSAIDs require that caution be taken when prescribing patients other anticoagulation or antiplatelet medications like clopidogrel. Taking these medications together can increase the risk of adverse reactions and/or potentiate toxicities.

9. Which one of the following descriptions defines the mind-body modality of guided imagery? A. A technique within this modality trains patients to develop awareness of experiences moment by moment and in the context of all senses. B. Enhances coordination and balance and promotes physical, emotional, and spiritual well-being. C. May lead the patient through progressive muscle relaxation or visualization of a treatment process (e.g., visualization of chemotherapy entering the body and seeking out cancer cells to remove them from the body). D. A psychotherapy technique based on the concept that distressing events are associated with specific rapid eye movements.

9. Answer: C Rationale: A technique in guided imagery is to lead the patient through progressive muscle relaxation or visualization of a treatment process (e.g., visualization of chemotherapy entering the body and seeking out cancer cells to remove them from the body). Tai chi is a modality that enhances coordination and balance and promotes physical, emotional, and spiritual well-being. Mindfulness-based stress reduction (MBSR) is a technique whereby patients are trained to develop awareness of experiences moment by moment and in the context of all senses. This technique falls under the larger category of meditation. A psychotherapy technique based on the concept that distressing events are associated with specific rapid eye movements is eye movement desensitization and reprocessing (EMDR).

21. Which of the following descriptions of cardiovascular toxicities is associated with the drug class of anthracyclines? A. Associated with toxicity from injury of free radicals that result in myocardial cell loss, fibrosis, and loss of contractility resulting in left ventricular dysfunction (LVD), HF, myopericarditis B. Associated with acute myopericarditis, pericardial effusions, arrhythmias, HTN, thromboembolism, and heart failure C. Associated with bradycardia, thromboembolism, and HTN may be seen D. Associated with coronary artery spasm resulting in angina, arrhythmia, myocardial infarction, cardiac arrest, and sudden death; coronary artery thrombosis and apoptosis of myocardial cells

Answer: A Rationale: Anthracyclines may cause toxicity from injury of free radicals that result in myocardial cell loss, fibrosis, and loss of contractility resulting in left ventricular dysfunction (LVD), HF, myopericarditis. Agents in this classification include doxorubicin, daunorubicin, epirubicin, idarubicin, mitoxantrone. Alkylating agents are associated with acute myopericarditis, pericardial effusions, arrhythmias, HTN, thromboembolism, and heart failure. An agent in this classification is cyclophosphamide. Angiogenesis inhibitors are associated with bradycardia, thromboembolism, and HTN may be seen, and agents in this classification include thalidomide, lenalidomide, and pomalidomide. Antimetabolites can cause coronary artery spasm resulting in angina, arrhythmia, myocardial infarction, cardiac arrest, and sudden death. Agents in this classification include 5FU, capecitabine, and gemcitabine.

Chapter 34 Cognitive Symptoms 1. S.L. is a 45-year-old breast cancer survivor who has undergone treatment with multimodal therapies. She is reporting having difficulty juggling multiple tasks at work. She is likely experiencing which one of the following? A. cognitive impairment B. decreased self-confidence C. delirium D. post-traumatic stress

Answer: A Rationale: Cognitive impairment is a functional decline in one or more cognitive domains including executive functioning. Post-traumatic stress is a mental disorder that can occur after a traumatic event. Delirium is associated with a disturbance in the level of an individual's attention and awareness. Decreased confidence is related to belief in one's own abilities.

4. J. L. is a 43-year-old colon cancer survivor who has completed treatment but is concerned about "chemo brain" affecting his work performance. Which one of the following interventions could be recommended for management of chemotherapy-induced impairment? A. Cognitive training B. Mindfulness stress reduction C. Donzepezil D. Methylphenidate

Answer: A Rationale: Cognitive training is an intervention that is likely to be effective in improving cognitive skills, such as attention or memory. Cognitive training often includes structured repetitive tasks aimed at improving a specific cognitive skill, such as memory or attention. Although the National Comprehensive Cancer Network (NCCN) guidelines suggest that a trial of psychostimulants be considered if non-pharmacological interventions are not effective, effectiveness of acetylcholinesterase inhibitors, N-methyl-D-aspartate receptors, or psychostimulants has not been established for management of cancer treatment-related cognitive impairment. Mindfulness stress reduction is typically utilized to decrease symptoms such as stress, anxiety, or pain.

12. Normal pericardial fluid volume is which one of the following measurements? A. 15-50 ml B. 50-80 ml C. 900-1000 ml D. 1-5 ml

Answer: A Rationale: Rapidly developing effusions may be symptomatic at 50 to 80 mL. Normal pericardial fluid volume is 15 to 50 mL.

17. A 70-year-old patient with advanced stomach cancer presents to the clinic with an infection. The nurse's assessment reveals poor performance status, presence of a venous access device, and lymphadenopathy. The nurse would recognize that the patient is at high risk for which one of the following conditions? A. a thrombotic event B. lymphedema C. malignant pericardial effusion D. cardiovascular toxicity

Answer: A Rationale: Risk factors for a thrombotic event include stomach, brain, pancreas, and bladder cancers, advanced stage, lymphadenopathy, infection, renal disease, poor performance status, prolonged immobilization and older age. Risk factors for lymphedema include advanced disease, infection, immobilization, or traumatic injury to an affected extremity. Risk factors for malignant pericardial effusion include mesothelioma direct tumor invasion of the myocardium, obstruction of mediastinal lymph nodes by tumor, infection, and fibrosis secondary to radiation therapy. Risk factors for cardiovascular toxicity include many classes of chemotherapy drugs.

8. The primary medical management of edema is to do which one of the following; A. treat the underlying cause. B. restrict beta blockers. C. increase sodium in diet. D. force fluids.

Answer: A Rationale: The treatment of the underlying cause of edema is the primary and most effective medical intervention. This includes treatment of congestive heart failure, nephrotic syndrome, liver failure/cirrhosis, thrombophlebitis, lymphedema, and deep vein thrombosis. Beta blockers may be indicated, not restricted, but would be after underlying cause is determined. Dietary sodium intake should be decreased, not increased. Fluid restriction, not increasing fluid intake, is recommended.

2. Which one of the following interventions would be an urgent priority for medical management of lymphedema? A. Treatment of suspected infection B. Weight management C. Exercise program D. Axillary reverse mapping (ARM)

Answer: A Rationale: Treatment of suspected infection by prescribing an antibiotic early will prevent further potentially life-threatening complications including serious bacterial infections of the skin (cellulitis) or an infection of the lymph vessels (lymphangitis). Weight management is important to reduce skin changes and potential infection but occurs over time, not as an urgent, acute management strategy. An exercise program is important but will also be over time, not as acute intervention. Axillary reverse mapping (ARM) facilitates identification and avoidance of arm lymphatics within the axilla during surgery and its use may reduce lymphedema. It is not an urgent priority; it is a prevention strategy

18. A 61-year-old patient with cancer presents to the clinic. A physical examination reveals severe pain in the patient's right leg. The right leg is also cool with a decreased pulse. This exam describes which one of the following conditions? A. venous occlusion B. arterial embolus C. pulmonary embolus D. valvular abnormality

Answer: B Rationale: Characteristics of an arterial embolus are severe pain in the involved extremity, extremity coolness, pallor, and absent or decreased pulse. Characteristics of venous occlusion would include tenderness over involved vein and unilateral edema of involved extremity. Characteristics of pulmonary embolus would include chest pain, dyspnea, sudden onset of anxiety, and decreased pulse oximetry. Valvular abnormality with S3 or S4 murmurs are characteristic of cardiovascular toxicity, not an embolus.

11. The most common characteristic or symptom of malignancy-related pericardial disease is which one of the following? A. gradual onset B. dyspnea C. productive cough D. abdominal distention

Answer: B Rationale: Dyspnea is the most common symptom with malignancy-related pericardial disease. The onset is sudden, not gradual. The cough is nonproductive, not productive. Distention may cause dyspnea but is not related to pericardial disease.

25. Findings related to edema of cancer include which one of the following? A. The presence of S2 heart sound. B. Decreased levels of serum albumin and protein. C. Increased peripheral pulses. D. Decreased blood pressure and heart rate.

Answer: B Rationale: Hypoproteinemia contributes to edema by fluids into the interstitial space. An S2 heart sound is normal. Blood pressure and pulse readings usually increase with edema, while peripheral pulses usually diminish as a result of poor cardiac output.

24. If a patient with breast cancer has not developed lymphedema in the first three years after surgery, which one of the following statements is true? A. She will probably not develop lymphedema in the arm. B. She must be instructed that the potential for lymphedema exists and she should report any issues. C. She probably had sentinel node mapping at the time of her initial surgery. D. She most likely benefited from breast conservation and radiation therapy.

Answer: B Rationale: Lymphedema may occur initially years after the surgical procedure has been completed, even if the patient has reported no previous problems. Less invasive breast surgery still requires lymph node dissection for staging. Sentinel node mapping does not eliminate the need for node dissection for biopsy, which can contribute to future lymphedema. Although less extensive node disruption with breast conservation and radiation therapy may well decrease the risk of lymphedema, those treatments do not eliminate the risk.

13. A patient's blood pressure (BP) is 120/80, pulse 60 and respirations 12. Thirty minutes later, the BP is 106/76, pulse 64, respirations 14. This difference in BP demonstrates which one of the following? A. imminent stroke B. narrowing pulse pressure C. widening pulse pressure D. pulsus paradoxus

Answer: B Rationale: Pulse pressure is the difference between systolic and diastolic pressure and "narrowing' if less than 40 mmHg. This occurs with pericardial effusions. There is not sufficient data with vital signs alone to indicate stroke, and the diagnosis needs physical assessment. Widening pulse pressure may be suggestive of valve regurgitation, aortic stenosis, or hyperthyroidism. Pulsus paradoxus refers to a decrease in blood pressure with inspiration and may be associated with a pulmonary embolism or hypovolemic shock.

19. Mild, spontaneously reversible, and slight heaviness of the extremity with smooth skin texture with pitting edema. Pain and erythema may be present. These characteristics of lymphedema describe which one of the following stages? A. 0 B. 1 C. 2 D. 3

Answer: B Rationale: Stage 1 edema is mild, spontaneously reversible, and presents with slight heaviness of the extremity with smooth skin texture with pitting edema. Pain and erythema may be present with stage 1. There is no stage 0; begins with stage 1. Stage 2 characteristics would be moderate, irreversible, with possible tissue fibrosis. The skin is stretched, shiny with non-pitting edema. Characteristics of stage 3 would be severe with lymphostatic elephantiasis, and is irreversible. The skin is discolored, stretched, and firm.

5. One of the hallmark symptoms in a patient with delirium when compared with other cognitive impairment is the presence of: A. decreased motor function B. hypervigilance C. impaired concentration D. memory changes

Answer: B Rationale: While changes in other cognitive domains (e.g. motor function, attention/concentration, and memory) may occur, an acute onset of hypervigilance or sedation is the classic symptom of delirium.

9. A primary diagnosis that commonly results in malignant pericardial effusion is which one of the following? A. basal cell skin cancer B. mesothelioma C. brain tumor D. amyloidosis

Answer: B Rationale: Mesothelioma is the most common diagnosis associated with malignant pericardial effusion. Melanoma, not basal cell, may be associated with malignant pericardial effusion if metastatic. Brain tumor is not a common cause of malignant pericardial effusion. Amyloidosis is not a common cause of malignant pericardial effusion.

15. Which of the following is a characteristic of an acute cardiovascular toxicity from chemotherapy? A. frequently occur. B. occurs within 7 days of drug administration. C. is usually reversible. D. requires discontinuation of the drug.

Answer: C Rationale: An acute reaction is reversible. Acute reactions are infrequent, occur within 24 hours of drug administration and usually self-limiting, and cease when the drug is stopped. They may not require discontinuation of the drug.

14. Which one of the following drug classifications is associated with the cardiovascular toxicity that can cause coronary artery spasm? A. Alkylating agents B. Anthracyclines C. Antimetabolites D. Angiogenesis inhibitors

Answer: C Rationale: Antimetabolites, such as 5FU, capecitabine, and gemcitabine, can cause coronary artery spasm resulting in angina, arrhythmia, myocardial infarction, cardiac arrest, and sudden death; coronary artery thrombosis and apoptosis of myocardial cells. Alkylating agents, such as cyclophosphamide, can cause, but not limited to, acute myopericarditis, pericardial effusions, and arrhythmias. Anthracyclines, such as doxorubicin, daunorubicin, and epirubicin, can cause toxicity from injury of free radicals that result in myocardial cell loss. Angiogenesis inhibitors, such as thalidomide and lenalidomide, can cause bradycardia, thromboembolism, and hypertension.

20. When the limb starts to look disfigured with over 30% difference in size at the greatest point of the limb and interferes with activities of daily living, which of the following grades of lymphedema would this be? A. 1 B. 2 C. 3 D. 4

Answer: C Rationale: In Grade 3 the limb starts to look disfigured, interferes with ADLs and there is more than 30% difference in size at greatest point or mass of limbs. In Grade 1 there is swelling, pitting edema, and a 5-10% difference in size at greatest point of limbs. In Grade 2 there is obvious obstruction, taut skin, and a 10-30% difference in size at greatest point of limbs. Grade 4 often progresses to malignancy is disabling and may need removal of affected extremity.

7. Which one of the following is a risk factors for edema? A. Increase in mobility B. Absent history of edema C. Long distance travel D. Hypotension

Answer: C Rationale: Long distance travel is a known risk factor. Decreased, not increased, mobility is a risk factor. A prior history of edema is a risk factor. Hypertension, not hypotension, is a risk factor.

4. H. K. is a 50-year-old female with breast cancer, who has been suffering from lymphedema. When the oncology nurse in her care is educating the patient about lymphedema management at home, which one of the following is an appropriate point for her to convey? A. Wear tight fitting clothes B. Consume diet high in sodium and low in fiber C. Maintain healthy weight D. Follow-up with health care team for 1 month

Answer: C Rationale: Maintenance of healthy weight is encouraged, since obesity is a risk factor for worsening of lymphedema. Loose, not tight, fitting clothes should be worn. The diet should be low sodium and high fiber. Lifelong, not short-term, follow-up will be necessary in persons with lymphedema.

6. Which one of the following is a risk factor for delirium in the cancer patient? A. Multimodality therapy B. Sensory impairments C. Metabolic abnormalities D. Genetic polymorphism

Answer: C Rationale: Treatment toxicities and tumor effects leading to metabolic abnormalities (e.g. calcium, glucose, sodium) may put patients at a higher risk for delirium. Individual characteristics such as advanced age and sensory impairments (e.g. visual, hearing) may contribute to both cognitive impairment and delirium. Dose intensity, cumulative effect, and/or multimodality therapy are risk factors for cognitive impairment. Genetic polymorphisms (e.g. APOE E4 allele) are associated with cancer-related cognitive impairment as well as dementia, but not delirium.

2. Which one of the following treatment modalities has the potential to stimulate cytokine dysregulation, resulting in cognitive impairment? A. Surgery B. Radiation therapy C. Chemotherapy D. Hormonal therapy

Answer: C. Rationale: Cancers, chemotherapy, and immunotherapy treatments can stimulate cytokine dysregulation leading to inflammation and oxidative stress, thus impairing cognition. Surgical removal of central nervous system tumors and/or cranial irradiation may result in structural and functional damage specific to the tumor location. Hormonal therapies impact cognition by altering levels of testosterone or estrogen.

Chapter 33 Cardiovascular Symptoms 1. Which one of the following is a treatment related risk factor for lymphedema? A. Lowered body mass index (BMI) B. Tumor invasion C. Prolonged immobilization D. Lymph node dissection

Answer: D Rationale: A lymph node dissection is related to treatment with surgery and is a treatment-related risk factor for developing lymphedema. An elevated BMI, not a lowered BMI, would be a nonmalignant-related risk factor. Tumor invasion is a cancer diagnosis-related risk factor, not a treatment-related risk factor. Prolonged immobilization is a cancer diagnosis-related risk factor, not a treatment-related risk factor.

22. Which one of the following techniques should oncology nurses use for the prevention of thrombotic events in high risk patients? A. Elevate the patient's foot with their knee extended. B. Elevate the patient's knee with their foot extended. C. Employ constant pneumatic compression device. D. Ambulate frequently, and implement leg exercises if the patient is bedridden.

Answer: D Rationale: Ambulating frequently, and implementing leg exercises, if the patient is bedridden, are techniques that are recommended for oncology nurses to use for the prevention of thrombotic events in high-risk patients. Elevating the patient's foot with their knee flexed is a recommended nursing management technique for prevention. Elevating the patient's foot with their knee extended and elevating the patient's knee with their foot extended are incorrect and not recommended. Finally, employing constant pneumatic compression device is not a recommendation. The recommendation is for the nurse to apply intermittent pressure.

3. When caring for the patient with lymphedema, the nurse would expect to see which one of the following interventions in the plan of care? A. Restrict exercise B. Dangle extremities C. Apply extreme heat D. Complete decongestive therapy

Answer: D Rationale: Complete decongestive therapy is the standard of care in the management of lymphedema. The use of compression garment is also recommended for practice in persons with lymphedema. Exercise would not be restricted but would be encouraged. The patient should be taught to elevate the affected extremity, not dangle it. Extreme heat may worsen the swelling.

3. B. H. is a 50-year-old male patient with metastatic prostate cancer. He reports bilateral decreased strength in his lower extremities. The nurse caring for him would anticipate receiving an order for which one of the following procedures? A. bone scan B. electrolytes, including calcium C. liver function tests D. magnetic resonance imaging

Answer: D Rationale: Either a CT or an MRI can be ordered to rule out structural abnormalities in patients with focal neurological deficits or who are at high risk for recurrence or metastatic central nervous system disease. A bone scan is more useful to evaluate the presence of an infection, fracture, or bone metastases. Laboratory tests are done to rule out more general causes of cognitive impairment, such as electrolytes for metabolic disturbances, or LFTs for liver dysfunction.

6. B. L is a 62-year-old patient who experiences edema after receiving plasma expanders. This condition would be documented as being caused by which one of the following? A. medication related B. allergic C. systemic D. iatrogenic

Answer: D Rationale: Iatrogenic causes of edema occur from plasma expanders, intravenous fluid overload, and blood components. Medications associated with edema may include treatment with hormones, calcium channel blockers, and steroids. An allergic response would be from histamine release. Systemic conditions include diagnoses such as heart failure, nephrotic syndrome, and liver failure.

16. Prevention of cardiotoxicity would include which one of the following nursing interventions for a patient receiving doxorubicin? A. Ensure patient treated for hyperlipidemia. B. Prescribe a beta blocker. C. Prescribe a calcium channel blocker. D. Document total cumulative dose of chemotherapy.

Answer: D Rationale: Nurses should document the total cumulative dose of chemotherapy. This is the only nursing intervention and prevention strategy listed. Doxorubicin maximum cumulative dose is 550 mg/m2, cumulative dose; mitoxantrone is 160 mg/m2 and high-dose cyclophosphamide is 144 mg/kg for 4 days and the nurse should document cumulative dose with each administration and know the maximum cumulative dose. Treating hyperlipidemia is a medical intervention and is used to treat cardiotoxicity, not prevent the complication. Prescription of a beta blocker is a medical intervention and is used to treat cardiotoxicity, not prevent the problem. Prescription of an ACE inhibitor and calcium channel blockers are used to treat hypertension.

10. A risk factor for malignant pericardial effusion is which one of the following? A. a fractionated radiation dose of 30 cGy/day to the iliac crest. B. simultaneous cancer treatment with hormones. C. coexisting renal infection. D. radiation targeted to more than 33% of the heart.

Answer: D Rationale: Radiation targeted to more than 33% of the heart with more than 300 cGy/day is a risk factor. Fraction doses of 300 cGy/day are tolerated by the heart, however, the iliac crest would not be in field of treatment. Hormones do not cause capillary permeability. Coexisting cardiac disease, lupus, or endocarditis would increase risk. Renal infection is not associated with malignant pericardial effusion.

23. Nursing management for treatment and prevention of issues related to lymphedema includes which one of the following? A. Implementing sterile technique before the administration of antineoplastic agents in the limb. B. Using an electronic or automated, rather than a manual, blood pressure cuff. C. Using massage therapy on and vigorous weightlifting with the affected limb. D. Recording regular measurement of extremities and elevating the affected limb.

Answer: D Rationale: Regular measurement of extremities facilitates early recognition of changes. Another action in nursing management for treatment and prevention is the use of elastic sleeves and grading wraps, which serve to facilitate movement of lymph out of the arm. The use of the sterile technique with antineoplastic agents is always indicated and is not specific to patients with lymphedema. It is also important to avoid use of a limb that is at risk for lymphedema. Carefully applied massage therapy has been shown to be beneficial, but vigorous weightlifting with the affected limb is not indicated. Moderate use limits risk, while allowing lymphatic fluid to drain normally.