Review 4
Physical assessment of a patient diagnosed with bulimia nervosa often reveals: a. prominent parotid glands b. peripheral edema c. thin, brittle hair d. amenorrhea
ANS: A
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. hematocrit 30% b. platelets 95,000/uL c. hemoglobin 10 g/L d. white blood counts (WBC) 2700/uL
ANS: D
During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looking away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient? a. risk for ineffective adherence to treatment related to denial for chemotherapy b. acute confusion related to infiltration of leukemia cells into the central nervous system c. deficient knowledge: chemotherapy related to a lack of interest in learning about treatment d. risk for ineffective health maintenance related to anxiety about new leukemia diagnosis
ANS: D
A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the client's white blood cell count (WBC) is high. What response by the registered nurse is best? a. if the WBCs are high, there already is an infection b. the client is in a blast crisis and has too many WBCs c. there must be a mistake, the WBCs should be very low d. those WBCs are abnormal and don't provide protection
ANS: D
A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best? a. because of immunosuppression, the donor cells take over b. its like a transfusion reaction because no perfect matches exist c. the clients cells are fighting donor cells for dominance d. the donors cells are actually attacking the clients cells
ANS: D
A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (SELECT ALL THAT APPLY) a. chemo gloves b. facemask c. isolation gown d. N95 respirator e. shoe covers f. goggles
ANS: A, B, C
A student studying leukemias learns the risk factor for developing this disorder. Which risk factors does this include? (SELECT ALL THAT APPLY) a. chemical exposure b. genetically modified foods c. ionizing radiation exposure d. vaccinations e. viral infections
ANS: A, C, E
A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate? a. assess the client for calf pain, warmth, and redness b. instruct the client to call for help to get out of bed c. obtain cultures as per the facilities standing policy d. place the client on productive isolation precautions
ANS: B
A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important? a. assess the client for a headache b. assist the client in getting out of bed c. instruct the client to reduce salt intake d. weigh the client daily before the client eats
ANS: B
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would include a need for further teaching? a. the pt ambulates around the room b. the pts visitors bring in fresh peaches c. the pt cleans with a warm washcloth after having a stool d. the pt uses soap and shampoo to shower every other day
ANS: B
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? a. encourage the pt to purchase a wig or hat and wear it once hair loss begins b. suggest that the pt limit social contacts until regrowth of the hair occurs c. teach the pt to wash their hair gently with mild shampoo to minimize hair loss d. inform the pt that hair usually grows back once chemotherapy is complete
ANS: A
A child with acute myeloblastic leukemia is scheduled to have a bone marrow transplant (BMT). The donor is the child's own umbilical cord blood that had been previously harvested and banked. This type of BMT is termed a. autologous b. allogenic c. syngeneic d. stem cell
ANS: A
A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? a. Epoetin alfa (Epogen) b. Filgrastim (Neupogen) c. Mesna (Mesnex) d. Oprelvekin (Neumega)
ANS: A
A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is the priority? a. assess blood pressure and pulse b. attach the client to a pulse oximeter c. have the client rate his or her pain d. start high-dose steroid therapy
ANS: A
A nurse cared for a client who has a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. the stool will always be liquid with this type of colostomy b. eating additional fiber will bulk up your stool and decrease diarrhea c. your stool will become firmer over the next couple of weeks d. this is abnormal. I will contact your health care provider
ANS: A
A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond? a. lets talk to the ostomy nurse to help you and your husband work through this b. you could try to wear longer lingerie that will better hide the ostomy appliance c. you should empty the push first so it will be less noticeable for your husband d. if you are not careful, you can hurt the stoma if you engage in sexual activity
ANS: A
A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first? a. client who has two bloody diarrhea stools this morning b. client who has been premeditated for nausea prior to chemotherapy c. client with a respiratory rate change from 18 to 22 breaths/min d. client with an unchanged lesion to the lower right lateral malleolus
ANS: A
A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. I am fat and ugly b. what I think about myself is my business c. I am grossly underweight, but that's what I want d. I am a few pounds overweight, but I can live with it
ANS: A
A women diagnosed with breast cancer had these laboratory tests performed at an office visit: -Alkaline phosphatase 125 U/L -Total calcium 12 mg/dL -Hematocrit 39% -Hemoglobin 14 g/dL. What test results indicate to the nurse that some further diagnostics are needed? a. elevated alkaline phosphatase and calcium suggests bone involvement b. only alkaline phosphate is decreased, suggesting liver metastasis c. hematocrit and hemoglobin are decreased, indicating anemia d. the elevated hematocrit and hemoglobin indicate dehydration
ANS: A
During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Obtain more information about the family history b. schedule a sigmoidoscopy to provide baseline data c. teach the pt about the need for a colonoscopy d. teach the pt how to do home testing for fecal occult blood
ANS: A
The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? a. shortness of breath (SOB) b. shivering and chills c. muscle aches and pains d. temperature of 100.2F (37.9C)
ANS: A
The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met? a. doing activities of daily living (ADLs) using rest periods b. helping plan a daily activity schedule c. requesting a sleeping pill at night d. telling visitors to leave when fatigued
ANS: A
The nurse notes that a child's gums bleed easily and that the child has bruising and petechiae on his extremities. What laboratory values are consistent with these symptoms? a. platelet count of 19,000/mm3 b. prothrombin time of 11-15 seconds c. hematocrit of 34 d. leukocyte count pf 14,000/mm3
ANS: A
While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? a. prioritization and administration of nursing care throughout the day b. completing all nursing care in the morning so the pt can rest the remainder of the day c. completing all nursing care in the evening when the pt is more rested d. limiting visitors, thus promoting the maximal amount of hours for sleep
ANS: A
As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented? a. amenorrhea b. alopecia c. lanugo d. stupor
ANS: C
A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which actions should the nurse take? a. contact provider and recommend a psychiatric consult for the client b. encourage the client to verbalize feelings about the feelings c. provide education about new treatment options with successful outcomes d. ask family and friends to visit the client and provide emotional support
ANS: B
A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected b. pt involved in decision making increases a sense of control and promotes compliance with the treatment c. a team approach to planning that diet ensures that physical and emotional needs of the pt are met d. because of increased risk for physical problems with referring, obtaining pt permission is required
ANS: B
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. binge eating disorder b. anorexia nervosa c. bulimia nervosa d. pica
ANS: B
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. infuse the medication over a short period of time b. stop the infusion if swelling is observed at the site c. administer the chemotherapy through a small-bore catheter d. hold the medication unless a central venous line is available
ANS: B
The nurse assessed a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? a. generalized muscle aches b. crackles heard at the lung bases c. complaints of nausea and anorexia d. oral temp of 100.6F (38.1C)
ANS: B
The nurse understands that the types of precautions needed for children receiving chemotherapy are based on which actions of chemotherapeutic agents? a. gastrointestinal upset b. bone marrow suppresion c. decreased creatinine level d. alopecia
ANS: B
The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a. yearly mammography for women aged 40 years and older b. using skin protection during sun exposure while at the beach c. colonoscopy at age 50 and every 10 years as follow-ups d. yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over
ANS: B
What behavior by a nurse caring for a patient diagnosed with an eating disorder indicates the nurse needs supervision? a. the nurses comments are compassionate and nonjudgemental b. the nurse uses an authoritarian manner when interacting with the patient c. the nurse teaches the pt to recognize signs of increasing anxiety and ways to intervene d. the nurse refers the pt to a self-help group for individuals with eating disorders
ANS: B
What is a priority nursing diagnosis for the 4-year-old child newly diagnosed with leukemia? a. ineffective breathing pattern related to mediastinal disease b. risk for infection. related to immunosuppressed state c. disturbed body image related to alopecia d. impaired skin integrity related to radiation therapy
ANS: B
What is the priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia? a. risk for injury related to poor blood clotting b. fatigue related to decreased cellular oxygenation c. disturbed body image related to skin color changes d. imbalanced nutrition, less than body requirements related to anorexia
ANS: B
A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended? a. complete blood count (CBC) b. culture and sensitivity c. prostate-specific antigen d. cystoscopy
ANS: C
A client has just returned from a right radical mastectomy. Which action but the unlicensed assistive personnel (UAP) would the nurse consider unsafe? a. checking the amount of urine in the urine catheter collection bag b. elevating the right are on a pillow c. taking the blood pressure on the right arm d. encourage the client to squeeze a rolled washcloth
ANS: C
A client is starting hormonal therapy with tamoxifen (Nolvadex) to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? a. it blocks the release of luteinizing hormone b. it interferes with cancer cell division c. it selectively blocks estrogen in the breats d. it inhibits DNA synthesis in rapidly dividing cells
ANS: C
A nurse has taught parents about diagnostic testing for their child who is suspected of having leukemia. What test described by the parents shows good understanding of this information? a. complete blood cell count (CBC) b. lumbar puncture c. bone marrow biopsy d. computed tomography (CT) scan
ANS: C
A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach his client? a. eat low-fiber and low-residual foods b. white rice and bread are easier to digest c. add vegetables such as broccoli and cauliflower to your new diet d. foods high in animal fat help to protect the intestinal mucosa
ANS: C
A patient who was referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patient's oral intake, the nurse should ask: a. do you often feel fat? b. who plans the family meals c. what do you eat in a typical day d. what do you think about your present weight
ANS: C
A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate? a. have the pt eat large meals when nausea is not present b. offer crackers and carbonated fluids during chemotherapy c. administer prescribed antiemetics 1 hour before the treatments d. give the pt a glass of a citrus fruit beverage during treatment
ANS: C
After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. pt who has a platelet count of 82,000/uL b. pt who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5F d. pt who is worried about getting the prescribed long-acting opioid on time
ANS: C
Parents of a child with acute lymphoblastic leukemia (ALL) ask about their child's prognosis. The nurse should base the response on the knowledge that a. leukemia is a fatal disease, although chemotherapy provides increasingly longer periods of remission b. research to find a cure for childhood cancers is very active c. the majority of children go into remission and remain symptom free when treatment is completed d. it usually takes several months of chemotherapy to achieve a remission
ANS: C
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective? a. the biopsy will remove the cancer in my prostate gland b. the biopsy will determine how much longer I have to live c. the biopsy will help decide the treatment for my enlarged prostate d. the biopsy will indicate whether the cancer has spread to other organs
ANS: C
What fluid is the best choice when a child with mucositis asks for something to drink? a. hot chocolate b. lemonade c. popsicle d. orange juice
ANS: C
With a history of breast cancer in the family, a 48-year-old female client is interested in learning about the modifiable risk factors for breast cancer. After the nurse explains this information, which statement made by the client indicates that more teaching is needed? a. I am fortunate that I breast-fed each day of my three children for 12 months b. it looks as though I need to start working out at the gym more often c. I am glad that we can still have wine with every evening meal d. when I have menopause symptoms, I must avoid hormone replacement therapy
ANS: C
A child with a history of fever of unknown origin, excessive bruising, lymphadenopathy, anemia, and fatigue is exhibiting symptoms most suggestive of which of the following? a. Ewing sarcoma b. wilms tumor c. neuroblastoma d. leukemia
ANS: D
A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. a 37 y/o who drinks eight cups of coffee daily b. a 44 y/o with irritable bowel syndrome (IBS) c. a 60 y/o lawyer who works 65 hours per week d. a 72 y/o who eats fast food frequently
ANS: D
A nurse has taught the parents about home care of their child who has leukemia. What statement made by the parents indicates an understanding of this teaching? a. we will take our Childs blood pressure daily b. we will restrict fluids in case there is central nervous system involvement c. we will make sure our child gets all immunizations in a timely manner d. we will take our childs temp frequently
ANS: D
A nurse is conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining pts concentration and attention b. shifting the pts focus from food to psychotherapy c. focusing on weight control mechanism and food preparation d. processing the heightened anxiety associated with eating
ANS: D
A nursing diagnosis for a patient diagnosed with bulimia nervosa is ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is, "Within 2 weeks the patient will: a. appropriately express angry feelings b. verbalize two positive things about self c. verbalize the importance of eating a balance diet d. identify two alternative methods of coping with loneliness
ANS: D
A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. anxiety, related to fear of weight gain b. disturbed body image, related to weight loss c. ineffective coping, related to lack of conflict resolution skills d. imbalanced nutrition; less than body requirements, related to self-starvation
ANS: D
A patient has been assigned the nursing diagnosis of imbalanced nutrition; less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. offer the pt frequent small snacks between meals b. assist the pt to choose favorite foods from the meal c. provide teaching about the importance of nutritional intake d. apply the ordered anesthetic gel to oral lesions before meals
ANS: D
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. pt complains of serve fatigue b. pt voids every hour during the day c. pt takes only 50% of meals and refuses snacks d. pt has crackles up to the midline posterior chest
ANS: D
