EAQ: Care of the patient with cancer
A nurse is caring for a patient who has a benign breast tumor. What are the characteristics that differentiate a benign tumor from a malignant tumor? Select all that apply. 1 Benign tumors are encapsulated. 2 Benign tumors are metastatic. 3 Benign tumors are well differentiated. 4 Benign tumors infiltrate the neighboring areas. 5 Benign tumors have a low rate of recurrence.
ANSWER: 1,3, 5 Benign tumors of the breast are encapsulated and have a well-defined border. They have well-differentiated cells. Once treated, benign tumors have a low rate of recurrence. Unlike malignant tumors, benign tumors are not metastatic and do not infiltrate the neighboring areas. Text Reference - p. 253
A nurse is caring for a patient undergoing brachytherapy for prostate cancer. Which are appropriate nursing interventions to protect oneself from radiation hazards? Select all that apply. 1 Limit close proximity to the patient to only those care tasks that must be performed near the source. 2 Share the film badge with a colleague who forgot his or her own badge. 3 Organize care to limit the time spent in direct contact with the patient. 4 Wear the film badge at all places of work to indicate your nature of work. 5 Use shielding when providing any care to the patient.
Answer 1,3,5 When working with patients receiving radiation therapy, the nurse should exercise all precaution to prevent radiation hazards. The precautions include using as low of a dose as possible, limiting the time and distance with and around patient, and shielding oneself. The nurse should organize care to limit the time spent in direct contact with the patient. The nurse should use shielding whenever possible. A film badge indicates cumulative radiation exposure, and all the health professionals in the radiation therapy unit should wear it. The badge should not be shared and should be worn only when working in the radiation therapy unit. Text Reference - p. 264
A patient with advanced metastatic lung cancer experiences fatigue, weakness, nausea, and vomiting. The patient's blood report shows a high level of calcium in the blood. How should the nurse interpret this lab finding? 1 The patient has a metabolic emergency. 2 The patient has cardiac tamponade. 3 The patient has a spinal cord compression syndrome. 4 The patient has a third space syndrome.
Answer: 1 Advanced cancers may result in metastasis to the bones, and cause increased levels of calcium in the blood. They may manifest as apathy, depression, fatigue, muscle weakness, ECG changes, polyuria and nocturia, anorexia, nausea, and vomiting. If untreated, it may result in nephrocalcinosis and irreversible renal failure. Cardiac tamponade manifests in a heavy feeling over the chest, shortness of breath, tachycardia, cough, dysphagia, hiccups, hoarseness, nausea, vomiting, excessive perspiration, decreased level of consciousness, distant or muted heart sounds, and extreme anxiety. Spinal cord compression syndrome manifests as intense, localized, and persistent back pain. The pain may be accompanied by vertebral tenderness. Third space syndrome manifests as low blood pressure, increased heart rate, low central venous pressure, and decreased urine output. Text Reference - p. 278
Which term would a nurse use to best describe loss of hair in small, round areas on the scalp? 1 Alopecia 2 Exotropia 3 Seborrhea 4 Amblyopia
Answer: 1 Alopecia is the correct term used for hair loss. Exotropia is a form of strabismus where the eyes deviate outward. Seborrhea, also known as dandruff, is a form of inflammation of the skin resulting in redness and flaking. It may be seen on any part of the body but is usually seen on the scalp. Amblyopia is a visual disturbance characterized by poor vision in one eye with or without structural abnormalities. Text Reference - p. 269
The laboratory report reveals that the cells from the patient's tumor biopsy are Grade II. What should the nurse know about this histologic grading? 1 Cells are abnormal and moderately differentiated. 2 Cells are very abnormal and poorly differentiated. 3 Cells are immature, primitive, and undifferentiated. 4 Cells differ slightly from normal cells and are well differentiated.
Answer: 1 Grade II cells are more abnormal than Grade I and moderately differentiated. Grade III cells are very abnormal and poorly differentiated. Grade IV cells are immature, primitive, and undifferentiated; the cell origin is difficult to determine. Grade I cells differ slightly from normal cells and are well differentiated. Text Reference - p. 254
Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which dietary modification should the nurse recommend? 1 A bland, low-fiber diet 2 A high-protein, high-calorie diet 3 A diet high in fresh fruits and vegetables 4 A diet emphasizing whole and organic foods
Answer: 1 Patients experiencing diarrhea secondary to chemotherapy or radiation therapy often benefit from a diet low in seasonings and roughage before the treatment. Foods should be easy to digest and low in fat. Fresh fruits and vegetables are high in fiber and should be minimized during treatment. Whole and organic foods do not prevent diarrhea.
A patient who is undergoing a course of outpatient chemotherapy reports feeling lonely and isolated and expresses the desire to resume normal activities, such as socialization with friends. Which precaution should the nurse recommend when allowing the patient to resume these activities? 1 Avoiding crowds 2 Drinking only bottled water 3 Refraining from eating outside the home 4 Using the bathroom at home, not in public places
Answer: 1 The nurse needs to teach the patient measures that will protect against infection, such as maintaining adequate nutrition and fluid intake and avoiding crowds, people with infections, and others who have been recently vaccinated with live or attenuated vaccines. Drinking bottled water, eating only at home, and using the bathroom only at home are unnecessary precautions. Text Reference - p. 266
A patient recently has been diagnosed with early stages of cervical cancer. Which of these interventions is most appropriate for the nurse to focus on at this time? Select all that apply. 1 Maintain the patient's hope. 2 Listen actively to the patient's fears and concerns. 3 Assist the patient in maintaining usual lifestyle patterns. 4 Discuss replacement child care for the patient's children. 5 Explain in detail the aspects of the upcoming radiation therapy.
Answer: 1,2,3 Provide essential information (not extreme details) regarding cancer and cancer care that is accurate and establishes realistic expectations about what the patient will experience. Maintaining hope is the key to effective cancer care. Hope varies, depending on the patient's status: hope that the symptoms are not serious, hope that the treatment is curative, hope for independence, hope for relief of pain, hope for a longer life, hope to achieve meaningful goals, or hope for a peaceful death. Hope provides control over what is occurring and is the basis of a positive attitude toward cancer and cancer care. It is also important to assist the patient in maintaining usual lifestyle patterns as much as possible. Discussing replacement childcare is not appropriate at this time. Text Reference - p. 279
A patient with ovarian cancer is receiving radiation therapy. A nurse finds that the patient has developed anemia as a side effect of radiation therapy. How should the nurse manage anemia in the patient? Select all that apply. 1 Monitor hemoglobin and hematocrit levels. 2 Monitor WBC count, especially neutrophils. 3 Administer iron supplements and erythropoietin. 4 Promote foods that increase hemoglobin levels. 5 Teach the patient to avoid large crowds and people with infections.
Answer: 1,3,4 The hemoglobin and hematocrit levels should be monitored to determine the severity of anemia and the effectiveness of the treatment. Iron supplements and erythropoietin are administered to increase hemoglobin levels. Promoting foods that increase hemoglobin levels help to treat anemia. Monitoring WBC counts and teaching the patient to stay away from crowds are management techniques done in cases of leukopenia. Text Reference - p. 266
The patient is receiving an intravenous (IV) vesicant chemotherapy drug. The nurse notices swelling and redness at the site. What should the nurse do first? 1 Ask the patient if the site hurts 2 Turn off the chemotherapy infusion 3 Call the prescribing health care provider 4 Administer sterile saline to the reddened area
Answer: 2 Because extravasation of vesicants may cause severe local tissue breakdown and necrosis, with any sign of extravasation the infusion first should be stopped, then the protocol for the drug-specific extravasation procedures should be followed to minimize further tissue damage. The site of extravasation usually hurts, but it may not. It is more important to stop the infusion immediately. The health care provider may be notified by another nurse while the patient's nurse starts the drug-specific extravasation procedures, which may or may not include sterile saline. Text Reference - p. 259
A patient is undergoing brachytherapy of the cervix and tells the nurse, "I feel like I'll be alone in this room forever!" What is the best response by the nurse? 1 "The staff is trying to provide privacy for you as much as possible." 2 "Is there a family member we can call to stay with you during the treatment?" 3 "Let me call your primary health care provider to see if the therapy can be removed early." Correct 4 "During the treatment, we have to limit how much time we are in your room, but the treatment will be finished soon."
Answer: 2 Brachytherapy consists of the implantation or insertion of radioactive materials directly into the tumor or adjacent to the tumor. Caring for the person undergoing brachytherapy or receiving radiopharmaceuticals requires the nurse to take special precautions. The principles of ALARA (as low as reasonably achievable) and of time, distance, and shielding are vital to health care professional safety when caring for the person with an internal radiation source. To minimize anxiety and confusion, tell the patient the reason for time and distance limitations before the procedure. The reason the patient is in isolation is not to provide privacy. It is not appropriate for a family member to put themselves at risk by staying with the patient. Therapy cannot be ceased early. Text Reference - p. 264
The nurse is administering a vesicant chemotherapy agent to a patient who has colon cancer. During rounds, the nurse notes that the intravenous site is reddened and swollen, and the patient complains that it is painful. What is the first action the nurse will take? 1 Slow the infusion rate. 2 Turn off the infusion. 3 Check the patient's vital signs. 4 Notify the primary health care provider.
Answer: 2 It is extremely important to monitor for and promptly recognize symptoms associated with extravasation of a vesicant and to take immediate action if it occurs. Immediately turn off the infusion and follow protocols for drug-specific extravasation procedures to minimize further tissue damage. It is not appropriate to slow the infusion rate. The health care provider should be notified, and vital signs checked, but they are not the first action that should be taken. Text Reference - p. 259
The nurse providing care for a patient with suspected cancer recalls that the only diagnostic procedure that is definitive for a diagnosis of cancer is: 1 MRI 2 Biopsy 3 CT scan 4 Tumor marker
Answer: 2 Only a biopsy is a definitive means of diagnosing cancer, because it actually identifies the pathological cells. Many tests, such as MRI, CT scan, and tumor markers, are indicative of cancer, but they do not confirm the presence of cancer cells as examination of a specimen obtained by biopsy does. Text Reference - p. 256
Following a surgery for colorectal cancer, the patient still has persistent carcinoembryonic antigen (CEA) levels. Which is a correct interpretation of high CEA levels? 1 The tumor has spread to other organs. 2 The tumor has not been completely removed. 3 The patient is suffering from chronic liver disease. 4 Carcinoembryonic antigen is not a reliable indicator.
Answer: 2 Persistent high CEA levels after surgery for colorectal cancer indicate that the tumor has not been removed completely. CEA is found on the surfaces of cancer cells derived from the gastrointestinal tract and from normal cells from the fetal gut, liver, and pancreas. CEA levels can be used as tumor markers that may be clinically useful to monitor the effect of therapy and indicate tumor recurrence. CEA can be affected by many factors, which need to be accounted for when reviewing these results. Text Reference - p. 253
A patient who has undergone a modified radical mastectomy sees the surgical site for the first time. The patient appears shocked and exclaims, "I look horrible! Will it ever look better?" Which response by the nurse is most appropriate? 1 "Would you like to meet another patient who's had a mastectomy?" 2 "You're shocked by the change in your appearance from the surgery?" 3 "After it heals and you're dressed, you won't even know you've had surgery." 4 "Don't worry. You know that the tumor is gone, and the area will heal very soon."
Answer: 2 When a patient appears shocked by her appearance after a mastectomy, the nurse should help her express her feelings and offer supportive care. Reflecting the patient's statement will allow her to expand and discuss her feelings. "After it heals" and "Don't worry" diminish the patient's distress regarding having undergone a modified radical mastectomy. "Would you like me to?" is an appropriate statement but does not allow the patient to verbalize her fears and concerns. Text Reference - p. 280
A nurse is learning about the different types of cancers. Which cancer has the highest incidence among men? 1 Lung cancer 2 Colon cancer 3 Prostate cancer 4 Thyroid cancer
Answer: 3 Among all the cancers in men, prostate cancer has the highest incidence (29%). Lung cancer has the highest death rate among men (29%). The incidence of colon cancer in males is 9%. Thyroid cancer is more common in women than men. Text Reference - p. 248
The patient with breast cancer is having teletherapy radiation treatments after surgery. What should the nurse teach the patient about the care of the skin? 1 Use Dial soap to feel clean and fresh 2 Scented lotion can be used on the area 3 Avoid heat and cold to the treatment area 4 Wear the new bra to comfort and support the area
Answer: 3 Avoiding heat and cold in the treatment area will protect it. Only mild soap and unscented, non-medicated lotions may be used to prevent skin damage . The patient will want to avoid wearing tight-fitting clothing, such as a bra, over the treatment field and will want to expose the area to air as often as possible. Text Reference - p. 269
A patient diagnosed with benign lipoma is concerned about the tumor spreading to other parts of the body. Which facts should the nurse include when teaching the patient about benign tumors? 1 Benign tumors are poorly differentiated. 2 Benign tumors have high recurrence rate. 3 Benign tumors are not capable of metastasis. 4 Benign tumors have moderate vascularity.
Answer: 3 Benign tumors are not metastatic and not capable of spreading from one organ to another. Benign tumors are normally differentiated, have low vascularity, and their recurrence is rare. Text Reference - p. 253
The patient is told that the adenoma tumor is not encapsulated, but has normally differentiated cells and that surgery will be needed. The patient asks the nurse what this means. What should the nurse tell the patient? 1 It will recur. 2 It has metastasized. 3 It is probably benign. 4 It is probably malignant.
Answer: 3 Benign tumors usually are encapsulated and have normally differentiated cells. They do not metastasize and rarely recur as malignant tumors do. Surgery is necessary because the tumor may become malignant and has the potential to cause health complications over time. Text Reference - p. 258
A nurse is caring for a patient with cancer of the neck. While assessing the vital signs of the patient, the nurse notices bleeding in the cancerous area. Which nursing action is a priority? 1 Start intravenous fluids. 2 Obtain a prescription for a blood transfusion. 3 Apply pressure on the site. 4 Inform the primary health care provider.
Answer: 3 Carotid artery rupture is a common complication in cancers of the head and neck. The artery can rupture due to invasion of the blood vessel wall by the tumor. It can also be caused by erosion of the arterial wall following surgery or radiation therapy. In the case of bleeding at the carotid artery, the nurse should immediately apply pressure on the bleeding site to stop bleeding. Intravenous fluids should be administered to maintain the intravascular volume; however, this intervention is not the priority. A blood transfusion may be necessary; however, it is not a priority. The primary health care provider should be informed after pressure is applied to the site of the bleeding. Text Reference - p. 278
The female patient is having whole brain radiation for brain metastasis. She is concerned about how she will look when she loses her hair. What is the best response by the nurse to this patient? 1 "When your hair grows back it will be patchy." 2 "Don't use your curling iron and that will slow down the loss." Correct 3 "You can get a wig now to match your hair so you will not look different." 4 "You should contact 'Look Good, Feel Better' to figure out what to do about this."
Answer: 3 Hair loss with radiation usually is permanent. The best response by the nurse is to suggest getting a wig before the patient loses her hair so she will not look or feel so different. When hair grows back after chemotherapy it is frequently a different color or texture. Avoiding use of electric hair dryers, curlers, and curling irons may slow the hair loss, but will not answer the patient's concern. The American Cancer Society's "Look Good, Feel Better" program will be helpful, but this response is avoiding the patient's immediate concern. Text Reference - p. 266
A nurse discusses chemotherapy treatment with a patient with colon cancer. Which body system does the nurse tell the patient is most susceptible to the side effects of commonly used antineoplastic drugs? 1 Lymphatic 2 Respiratory 3 Bone marrow 4 Cardiovascular
Answer: 3 One of the most common side effects of chemotherapeutic drugs is bone marrow suppression, which decreases the production of blood cells. Bone marrow is susceptible to chemotherapy because of the rapid cell cycles and replacement of blood-forming tissue in bone marrow. The lymphatic, respiratory, and cardiovascular systems may be affected by chemotherapy drugs but vary in their levels of severity and involvement, whereas bone marrow suppression is common in all forms of antineoplastic therapy. Text Reference - p. 266
The patient has osteosarcoma of the right leg. The unlicensed assistive personnel (UAP) reports that the patient's vital signs are normal, but the patient says there is still pain in the leg and it is getting worse. What assessment question should the nurse ask the patient to determine treatment measures for this patient's pain? 1 "Where is the pain?" 2 "Is the pain getting worse?" 3 "What does the pain feel like?" 4 "Do you use medications to relieve the pain?"
Answer: 3 The UAP told the nurse the location of the patient's pain and the worsening of pain (pattern). Asking about the quality of the pain will help in planning further treatment. The nurse should already know if the patient is using medication to relieve the pain or can check the patient's medication administration record to see if analgesics have been administered. The intensity of pain using a pain scale also should be assessed. Text Reference - p. 279
The oncologist has told the patient that he or she has a benign tumor in the liver. The patient asks the nurse, "What is the main difference between benign and malignant tumors?" Which answer by the nurse is correct? 1 "Malignant tumors usually are encapsulated." 2 "Malignant tumors have a rare recurrence rate." 3 "Benign tumors do not invade and spread to other organs." 4 "Malignant tumors require less nutrients for their cells than benign tumors."
Answer: 3 The ability of malignant tumor cells to invade and metastasize is the major difference between benign and malignant neoplasms. Benign tumors usually are encapsulated; metastasis is absent, and recurrence is rare. Malignant tumors rarely are encapsulated, are capable of metastasis, and are capable of recurring. Text Reference - p. 253
The nurse is discussing the effects of chemotherapy with a patient who has a new diagnosis of cancer. Which statement by the patient reflects an adequate understanding of the teaching? 1 "I will need to use effective birth control methods for the rest of my life." 2 "My doctor will stop the chemotherapy if nausea and vomiting occur during treatment." 3 "I will join a support group after my therapy is finished to help me get back on my feet." 4 "I probably won't be able to do anything I used to do anymore now that I have cancer."
Answer: 3 The impact of a cancer diagnosis can affect many aspects of a patient's life, with cancer survivors commonly reporting financial, vocational, marital, and emotional concerns even long after treatment is over. These psychosocial effects can play a profound role in a patient's life after cancer, with issues related to living in uncertainty being encountered frequently. Participation in appropriate supportive care and community resources would benefit the patient in recovery or ongoing care. It will not be necessary for the patient to use birth control for the rest of the patient's life; nausea and vomiting are expected effects of chemotherapy and treatment will continue unless the vomiting becomes severe. Text Reference - p. 61
A nurse finds that the patient undergoing radiotherapy has developed erythema and desquamation. Which measure should the nurse include when teaching the patient about skin care in the radiation treatment area? 1 Wear fabrics such as wool and corduroy to prevent exposure to cold. 2 Use perfumes and cosmetics on the treatment area as desired. 3 Gently cleanse the skin using a mild soap, tepid water, and a soft cloth. 4 Allow brief periods of direct exposure to sunlight for good bone health.
Answer: 3 The skin should be gently cleansed using a mild soap, tepid water, and a soft cloth. Fabrics such as wool and corduroy should not be worn, as they can traumatize the skin. Chemicals like perfumes, cosmetics, and powders should not be used on the treatment area, as they are harsh on skin and can increase the irritation of the skin. The skin should not be exposed to direct sunlight. Protective clothing should be worn, if exposure to sun is expected. Text Reference - p. 270
A nurse is caring for a patient with breast cancer who is receiving chemotherapy. The patient has developed alopecia as a result of chemotherapy and is noticeably upset about what happened. Which nursing actions are appropriate for this patient? Select all that apply. 1 Instruct the patient to use shampoo every day. 2 Instruct the patient to brush and comb hair frequently. 3 Suggest the patient use scarves and wigs. 4 Suggest the patient cut long hair before therapy. 5 Instruct the patient to avoid the use of hair dryers.
Answer: 3,4,5 Alopecia refers to loss of hair from the head or the body and is a common side effect of cancer treatment. The patient can use scarves and wigs to improve body image. Long hair should be cut before therapy, as it needs more care and is more prone to fall out. Hair dryers should be avoided as their use can worsen alopecia. Shampoos are chemicals that may harm the hair and should not be used daily. Brushing and combing should be done carefully and infrequently, as excessive brushing and combing can worsen alopecia. Text Reference - p. 266
When caring for the patient with cancer, the nurse understands that which of the following is the response of the immune system to antigens of the malignant cells? 1 Metastasis 2 Tumor angiogenesis 3 Immunologic escape 4 Immunologic surveillance
Answer: 4 Immunologic surveillance is the process where lymphocytes check cell surface antigens, and detect and destroy cells with abnormal or altered antigenic determinants to prevent these cells from developing into clinically detectable tumors. Metastasis is increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site in the progression stage of cancer development. Tumor angiogenesis is the process of blood vessels forming within the tumor itself. Immunologic escape is the cancer cells evasion of immunologic surveillance that allows the cancer cells to reproduce. Text Reference - p. 252
Which item would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy? 1 Firm-bristle toothbrush 2 Hydrogen peroxide rinse 3 Alcohol-based mouthwash 4 1 tsp salt in 1 L water mouth rinse
Answer: 4 A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because of mucositis, which is a side effect of chemotherapy. A soft-bristle toothbrush should be used. Hydrogen peroxide and alcohol-based mouthwash are not used because they would damage the oral tissue. Text Reference - p. 268
A patient has been diagnosed with Burkitt's lymphoma. In the initiation stage of cancer, the cells' genetic structure is mutated. Exposure to what may have had the greatest impact as a carcinogen for this patient? 1 Bacteria 2 Sun exposure 3 Most chemicals 4 Epstein-Barr virus
Answer: 4 Burkitt's lymphoma consistently shows evidence of the presence of Epstein-Barr virus in vitro. Bacteria do not initiate cancer. Sun exposure causes cell alterations leading to melanoma and squamous and basal cell skin carcinoma. Long-term exposure to certain chemicals (e.g., ethylene oxide, chloroform, benzene) is known to initiate cancer. Text Reference - p. 251
The nurse caring for a patient undergoing chemotherapy finds that the patient has a low white blood cell (WBC) count. Which is an appropriate intervention? 1 Request that the chemotherapy dose be reduced. 2 Monitor the respiratory rate of the patient. 3 Allow the patient to visit with family and friends. 4 Administer white blood cell growth factors.
Answer: 4 Chemotherapy may suppress the proliferation of bone marrow resulting in neutropenia or low white blood cell counts. Low WBC count makes the patient prone for developing infection; therefore, the nurse should consult the health care provider and get WBC growth factors administered. In addition, the nurse should monitor the temperature of the patient, as it can indicate fever. The number of visitors should be limited to prevent risk of infection. The chemotherapy dose need not be reduced, as neutropenia is a common side effect. Respiratory rate is routinely monitored, but in this case it is not directly related to the patient's WBC. Text Reference - p. 265
The nurse is reviewing the role of the immune system in cancer development. Which of these statements explains the primary protective role of the immune system related to malignant cells? 1 Immune cells bind with free antigen released by malignant cells. 2 Immune cells produce blocking factors that immobilize cancer cells. 3 The immune system produces antibodies that attack the cancer cells. 4 The immune system provides surveillance for cells with tumor-associated antigens (TAAs).
Answer: 4 It is believed that one of the functions of the immune system is to respond to TAAs, which are altered cell-surface antigens that occur on a cancer cell as a result of malignant transformation. This immune function is known as immunologic surveillance. Immune cells do not bind with free antigens released by malignant cells, nor do they produce blocking factors that immobilize cancer cells. The immune system does not produce antibodies to attack cancer cells. Text Reference - p. 252
Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? 1 Acute pain 2 Hypothermia 3 Powerlessness 4 Risk for infection
Answer: 4 Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia, powerlessness, and acute pain also are possible nursing diagnoses for patients undergoing chemotherapy, but the threat of infection is paramount. Text Reference - p. 265
A patient undergoes modified radical mastectomy with axillary node dissection. After the surgical incision is sufficiently healed, the patient is to undergo radiation therapy. What instruction should the nurse give the patient regarding care of the skin at the site of radiation therapy? 1 Expose the area to sunlight twice a week 2 Apply an ointment to the area to prevent irritation 3 Apply talcum powder to the area to promote comfort 4 Wash the area gently with lukewarm water and lightly pat it dry
Answer: The area undergoing radiation therapy may safely be washed with lukewarm water if it is done gently and if care is taken not to injure the skin. A patient undergoing radiation therapy should avoid anything that may be irritating to the skin, such as sunlight, lotions, ointments, or talcum powder. Text Reference - p. 269
