Chapter 15

11. A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? a.Minimize activity until the treatment is completed. b.Establish time to take a short walk almost every day. c.Consult with a psychiatrist for treatment of depression. d.Arrange for delivery of a hospital bed to the patient's home.

NS: B Walking programs are used to keep the patient active without excessive fatigue. Having a hospital bed does not necessarily address the fatigue. The better option is to stay as active as possible while combating fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility. DIF: Cognitive Level: Apply (application) REF: 253TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate? a."The cancer involves only the cervix." b."The cancer cells look like normal cells." c."Further testing is needed to determine the spread of the cancer." d."It is difficult to determine the original site of the cervical cancer."

ANS: A Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread. DIF: Cognitive Level: Apply (application) REF: 241TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

37. 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 b.Shivering and chills c.Muscle aches and pains d.Temperature of 100.2° F (37.9° C)

ANS: A Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. Thenurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse, but are not indicative of life-threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 258OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

16. A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem?a.Encourage the patient to purchase a wig or hat to wear when hair loss begins .b.Suggest that the patient limit social contacts until regrowth of the hair occurs. c.Teach the patient to wash hair gently with mild shampoo to minimize hair loss. d.Inform the patient that hair usually grows back once chemotherapy is complete.

ANS: A The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicles and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem. DIF: Cognitive Level: Apply (application) REF: 256TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

5. 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 patient about the need for a colonoscopy at age 50. d.Teach the patient how to do home testing for fecal occult blood

ANS: A The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that isobtained from the patient with further questioning. DIF: Cognitive Level: Analyze (analysis) REF: 241TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

33. When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel(UAP) indicates a need for the nurse to intervene?a.The UAP assists the patient to use dental floss after eating.b.The UAP adds baking soda to the patient's saline oral rinses.c.The UAP puts fluoride toothpaste on the patient's toothbrush.d.The UAP has the patient rinse after meals with a saline solution.

ANS: A Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient. DIF: Cognitive Level: Apply (application) REF: 261OBJ: Special Questions: Delegation TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment

22. Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? a.IL-2 enhances the body's immunologic response to tumor cells. b.IL-2 prevents bone marrow depression caused by chemotherapy. c.IL-2 protects normal cells from harmful effects of chemotherapy. d.IL-2 stimulates malignant cells in the resting phase to enter mitosis.

ANS: A IL-2 enhances the ability of the patient's own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cellsto enter mitosis, or prevent bone marrow depression. DIF: Cognitive Level: Understand (comprehension) REF: 258TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

1. The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? a.Pap testing b.Tobacco use c.Sunscreen use d.Mammography e.Colorectal screening

ANS: A, C, D, EThe patient's age, gender, and history indicate a need for screening and teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use tobacco or excessive alcohol, she is physically active, and her body weight is healthy.DIF: Cognitive Level: Analyze (analysis) REF: 235TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

Maintenance2. A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? a.Cook food thoroughly before eating. b.Choose low fiber, low residue foods. c.Avoid public transportation such as buses. d.Use rectal suppositories if needed for constipation. e.Talk to the oncologist before having any dental work.

ANS: A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics. DIF: Cognitive Level: Apply (application) REF: 253TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

34. The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?a.The UAP flushes the toilet once after emptying the patient's bedpan.b.The UAP stands by the patient's bed for 30 minutes talking with the patient.c.The UAP places the patient's bedding in the laundry container in the hallway.d.The UAP gives the patient an alcohol-containing mouthwash to use for oral care

ANS: B Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine and feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated. DIF: Cognitive Level: Apply (application) REF: 250OBJ: Special Questions: Delegation TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment

30. The nurse assesses 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 temperature of 100.6° F (38.1° C)

ANS: B Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin-2. The patient may need oxygen and the nurse should rapidly notify the health care provider. The other findings are common side effects of interleukin-2. DIF: Cognitive Level: Analyze (analysis) REF: 257TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

23. The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a."I have frequent muscle aches and pains." b."I rarely have the energy to get out of bed." c."I experience chills after I inject the interferon." d."I take acetaminophen (Tylenol) every 4 hours."

ANS: B Fatigue can be a dose-limiting toxicity for use of immunotherapy. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use acetaminophen every 4 hours. DIF: Cognitive Level: Apply (application) REF: 258TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

28. A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?a.The patient ambulates around the room.b.The patient's visitors bring in fresh peaches.c.The patient cleans with a warm washcloth after having a stool.d.The patient uses soap and shampoo to shower every other day.

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteriabeing present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection. DIF: Cognitive Level: Apply (application) REF: 253TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

4. The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer? a.Fruit salad b.Baked chicken c.Creamed broccoli d.Toasted wheat bread

ANS: B Protein is needed for wound healing. To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products should also be avoided. DIF: Cognitive Level: Apply (application) REF: 254TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

38. A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first? a.Give the patient the prescribed PRN opioid. b.Assess for sensation and strength in the legs. c.Notify the health care provider about the symptoms. d.Teach the patient how to use relaxation to reduce pain.

ANS: B Spinal cord compression, an oncologic emergency, can occur with invasion of tumor into the epidural space. The nurse will need to assess the patient further for symptoms such as decreased leg sensation and strength and then notify the health care provider. Administration of opioids or the use of relaxation may be appropriate but only after the nurse has assessed forpossible spinal cord compression. DIF: Cognitive Level: Analyze (analysis) REF: 264OBJ: Special Questions: Prioritization TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

15. 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 Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices are preferred. DIF: Cognitive Level: Analyze (analysis) REF: 246TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

24. A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan? a.Donor bone marrow is transplanted through a sternal or hip incision. b.Hospitalization is required for several weeks after the stem cell transplant. c.The transplant procedure takes place in a sterile operating room to minimize the risk for infection. d.Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone.

ANS: B The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCTwhile waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line so the transplant is not painful, nor is an operating room or incision required. DIF: Cognitive Level: Understand (comprehension) REF: 261TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

20. A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?a."Don't you have any friends that will raise the children for you?" b."Would you like to talk about options for the care of your children?" c."For now you need to concentrate on getting well and not worrying about your children." d."Many patients with cancer live for a long time, so there is time to plan for your children."

ANS: B This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning "Many patients with cancer live for a long time" and "For now you need to concentrate on getting well" close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's friends will raise the children, more assessment information is needed before making plans. DIF: Cognitive Level: Apply (application) REF: 265TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

25. The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a.Lime sherbet b.Blueberry yogurt b.Blueberry yogurt d.Cream cheese bagel

ANS: B Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Lime sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein. DIF: Cognitive Level: Apply (application) REF: 261TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

12. The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?a.The patient has a history of dental caries. b.The patient swims several days each week. c.The patient snacks frequently during the day. d.The patient showers each day with mild soap

ANS: B The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change habits of eating frequently or showeringwith a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation. DIF: Cognitive Level: Apply (application) REF: 255TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. 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 A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. A biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life. DIF: Cognitive Level: Apply (application) REF: 238TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

9. A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure? a.Pain will be relieved by cutting sensory nerves in the stomach. b.Relief of pressure in the stomach will promote better nutrition. c.Decreasing the tumor size will improve the effects of other therapy. d.Tumor growth will be controlled by the removal of malignant tissue.

ANS: C A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs. DIF: Cognitive Level: Understand (comprehension) REF: 245TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? a."I can use ice packs to relieve itching." b."I will scrub the area with warm water." c."I can buy aloe vera gel to use on my skin." d."I will expose my skin to a sun lamp each day."

ANS: C Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury. DIF: Cognitive Level: Apply (application) REF: 255TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

35. The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a.A 35-yr-old patient who has wet desquamation associated with abdominal radiation b.A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c.A 24-yr-old patient who received neck radiation and has blood oozing from the neck d.A 56-yr-old patient who developed a new pericardial friction rub after chest radiation

ANS: C Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 263OBJ: Special Questions: Multiple Patients TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment

21. A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? a.The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). b.The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. c.The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d.The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.

ANS: C For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics may also be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved.The IV route is not more effective than the oral route, and usually the oral route is preferred. DIF: Cognitive Level: Apply (application) REF: 264TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

10. External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a.Test all stools for the presence of blood. b.Maintain a high-residue, high-fiber diet. c.Clean the perianal area carefully after every bowel movement. d.Inspect the mouth and throat daily for the appearance of thrush.

ANS: C Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and causefrequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation. DIF: Cognitive Level: Apply (application) REF: 251TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

41. After change-of-shift report on the oncology unit, which patient should the nurse assess first? a.Patient who has a platelet count of 82,000/µL after chemotherapy b.Patient who has xerostomia after receiving head and neck radiation c.Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d.Patient who is worried about getting the prescribed long-acting opioid on time

ANS: C Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/µL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patientdoes not appear to have breakthrough pain. DIF: Cognitive Level: Analyze (analysis) REF: 253OBJ: Special Questions: Prioritization | Special Questions: Multiple PatientsTOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

2. The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a.Nausea b.Alopecia c.Hematuria d.Xerostomia

ANS: C The adverse effects of intravesical chemotherapy are confined to the bladder. The other adverse effects are associated with systemic chemotherapy. DIF: Cognitive Level: Apply (application) REF: 252TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

1. A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a."Benign tumors do not cause damage to other tissues." b."Benign tumors are likely to recur in the same location." c."Malignant tumors may spread to other tissues or organs." d."Malignant cells reproduce more rapidly than normal cells."

ANS: C The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors do not metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur. DIF: Cognitive Level: Understand (comprehension) REF: 240TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a."After cancer has not recurred for 5 years, it is considered cured." b."The cancer will be cured if the entire tumor is surgically removed." c."I will need follow-up examinations for many years after treatment before I can beconsidered cured." d."Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation."

ANS: C The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up. DIF: Cognitive Level: Apply (application) REF: 243TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

39. The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider?a.Hematocrit of 32% b.Pain with deep inspiration c.Serum sodium of 126 mEq/L d.Decreased breath sounds on left side

ANS: C The syndrome of inappropriate antidiuretic hormone (and the resulting hyponatremia) is an oncologic metabolic emergency and requires rapid treatment to prevent complications such as seizures and coma. The other findings also require intervention but are common in patients with lung cancer and not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 263OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

4. 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 patient eat large meals when nausea is not present. b.Offer dry crackers and carbonated fluids during chemotherapy. c.Administer prescribed antiemetics 1 hour before the treatments. d.Give the patient a glass of a citrus fruit beverage during treatments.

ANS: C Treatment with antiemetics before chemotherapy may help prevent nausea. The patient shouldeat small, frequent meals. Offering food and beverages during chemotherapy is likely to causenausea. The acidity of citrus fruits may be further irritating to the stomach. DIF: Cognitive Level: Apply (application) REF: 251TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

29. The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the needfor psychologic support, which question by the nurse will provide the most information?a."How long ago were you diagnosed with this cancer?"b."Do you have any concerns about body image changes?"c."Can you tell me what has been helpful to you in the past when coping with stressful events?"d."Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"

ANS: CInformation about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient's need for support. The patient's knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Because surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time.DIF: Cognitive Level: Apply (application) REF: 265TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

26. A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem? a.Add protein powder to foods such as casseroles. b.Tell the patient to eat foods that are high in nutrition. c.Avoid giving the patient foods that are strongly disliked.d.Add spices to enhance the flavor of foods that are served.

ANS: CThe patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding protein powder does not address the issue of taste. The patient's poor intake is not caused by alack of information about nutrition.DIF: Cognitive Level: Apply (application) REF: 262TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. 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 patient frequent small snacks between meals. b.Assist the patient to choose favorite foods from the menu. c.Provide teaching about the importance of nutritional intake. d.Apply prescribed anesthetic gel to oral lesions before meals.

ANS: D Because the etiology of the patient's poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition but would not be as helpful for this patient. DIF: Cognitive Level: Analyze (analysis) REF: 254TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

40. An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?a.Patient complains of severe fatigue. b.Patient voids every hour during the day. c.Patient takes only 50% of meals and refuses snacks. d.Patient has crackles up to the midline posterior chest.

ANS: D Rapid fluid infusions may cause heart failure, especially in older patients. The other findings are common in patients who have cancer or are receiving chemotherapy. DIF: Cognitive Level: Analyze (analysis) REF: 266OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

3. The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer? a.Teach the patient about the seven warning signs of cancer. b.Plan to monitor the patient's carcinoembryonic antigen (CEA) level. c.Teach the patient about annual chest x-rays for lung cancer screening. d.Discuss risks associated with cigarette smoking during each patient encounter.

ANS: D Teaching about the risks associated with cigarette smoking is recommended at every patient encounter because cigarette smoking is associated with multiple health problems. The other options may detect lung cancer that is already present but do not reduce the risk. DIF: Cognitive Level: Apply (application) REF: 237TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

17. A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he does not know what to say to hiswife. Which nursing diagnosis is appropriate for the nurse to add to the plan of care? a.Compromised family coping related to disruption in lifestyle b.Impaired home maintenance related to perceived role changes c.Risk for caregiver role strain related to burdens of caregiving responsibilities d.Dysfunctional family processes related to effect of illness on family members

ANS: D The data indicate that this diagnosis is most appropriate because poor communication among the family members is affecting family processes. No data suggest a change in lifestyle or its role as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities. DIF: Cognitive Level: Apply (application) REF: 265TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

32. 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/µL c.Hemoglobin 10 g/L d.White blood cells (WBC) 2700/µL

ANS: D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy. DIF: Cognitive Level: Apply (application) REF: 235OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

18. A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?a.Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b.Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c.Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d.Rinse the mouth before and after each meal and at bedtime with a saline solution.

ANS: D The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended. DIF: Cognitive Level: Apply (application) REF: 251TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

31. The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider? a.Frequent loose stools b.Nausea and vomiting c.Elevated white blood count (WBC) d.Increased carcinoembryonic antigen (CEA)

ANS: DAn increase in CEA indicates that the chemotherapy is not effective for the patient's cancer and may need to be modified. Gastrointestinal adverse effects are common with chemotherapy. The nurse may need to address these, but they would not necessarily indicate aneed for a change in therapy. An elevated WBC may indicate infection but does not reflect theeffectiveness of the colorectal cancer therapy.DIF: Cognitive Level: Apply (application) REF: 236TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

27. During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks 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 of need 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 possible anxiety about leukemia diagnosis

ANS: DThe patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patient's history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiologic factors.DIF: Cognitive Level: Apply (application) REF: 265TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

36. Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?a.Teach the patient to rest the brain by avoiding new activities.b.Teach that "chemo-brain" is a short-term effect of chemotherapy.c.Report patient symptoms immediately to the health care provider.d.Suggest use of a daily planner and encourage adequate rest and sleep.

ANS: DUse of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop "chemo-brain" while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short or long term. There is no urgent need to report common chemotherapy side effects to the provider.DIF: Cognitive Level: Apply (application) REF: 252TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity