Exam 4
After teaching a client with immunodeficiency about ways to prevent infection, the nurse determines that teaching was successful when the client makes which statement? "I should avoid eating cooked fruits and vegetables." "I should avoid being around other people who have an infection." "Alcohol is good to clean any skin areas that are dry or chafed." "I will clean my kitchen counter with hot water."
"I should avoid being around other people who have an infection."
Which substance most easily transmits the human immunodeficiency virus (HIV)? A.Blood B.Feces C.Saliva D.Urine
A.Blood
An oncology client has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis? Avoid skin contact with water whenever possible Apply phototherapy PRN Apply an ice pack or heating pad PRN to relieve pain and pruritis Avoid rubbing or scratching the affected area
Avoid rubbing or scratching the affected area Explanation: Rubbing and or scratching will lead to additional skin irritation, damage, and increased risk of infection. Extremes of hot, cold, and light should be avoided. There is no need to avoid contact with water.
Which blood test confirms the presence of antibodies to HIV? Erythrocyte sedimentation rate (ESR) p24 antigen Enzyme-linked immunosorbent assay (ELISA) Reverse transcriptase
Enzyme-linked immunosorbent assay (ELISA)
A client suspected of having human immunodeficiency virus (HIV) asks the nurse what causes AIDS. What is the best response by the nurse? The streptococcal bacteria The Epstein-Barr virus The staphylococcal bacteria The human immunodeficiency virus
The human immunodeficiency virus
A client arrives at the clinic and reports a very sore throat as well as a fever. A rapid strep test returns a positive result and the client is given a prescription for an antibiotic. How did the streptococcal organism gain access to the client to cause this infection? Breathing in airborne dust From being outside in the cold weather and decreasing resistance Through the skin Through the mucous membranes of the throat
Through the mucous membranes of the throat
According to the TNM classification system, T0 means there is no evidence of primary tumor. distant metastasis. no distant metastasis. no regional lymph node metastasis.
no evidence of primary tumor. Explanation: T0 means that there is no evidence of primary tumor. N0 means that there is no regional lymph node metastasis. M0 means that there is no distant metastasis. M1 means that there is distant metastasis.
The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment? Palpation of the client's liver Percussion of the client's abdomen Auscultation of the client's apical heart rate Palpation of the client's lymph nodes
Palpation of the client's lymph nodes
A nurse is exposed to hepatitis C and receives a shot of gamma globulin. What type of immunity does this nurse have? Artificially acquired active immunity Natural immunity Passive immunity Naturally acquired active immunity
Passive immunity
During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses: acquired immunity. natural immunity. humoral immunity. phagocytic immunity.
acquired immunity.
The nurse is teaching the client with HIV about therapy. Which elements are essential for the nurse to include in the teaching plan? Select all that apply. The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle. Medication therapy is rarely effective. Clients rarely respond to medication therapy. The goal of antiretroviral therapy is to prevent opportunistic infections.
The CD4 count is the major indicator of immune function and guides therapy. Antiretroviral therapy targets different stages of the HIV life cycle.
A nurse is caring for a client diagnosed with human immunodeficiency virus (HIV). The client wants to know when medication for the disease will begin. What is the nurse's best response? If the client has a CD4 T-cell count less than 350 cells/mm3. When the client is coinfected with hepatitis C. If the client is diagnosed with HIV-associated liver disease. After the client has been cured of Kaposi's sarcoma.
If the client has a CD4 T-cell count less than 350 cells/mm3.
What disadvantages of chemotherapy should the patient be informed about prior to starting the regimen? It causes a systemic reaction. It targets normal body cells as well as cancer cells. It attacks cancer cells during their vulnerable phase. It functions against disseminated disease.
It targets normal body cells as well as cancer cells. Explanation: Chemotherapy agents affect both normal and malignant cells; therefore, their effects are often widespread, affecting many body systems.
When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction? "Put on disposable gloves before bathing." "Avoid eating foods from serving dishes shared by other family members." "Sterilize all plates and utensils in boiling water." "Avoid sharing such articles as toothbrushes and razors."
"Avoid sharing such articles as toothbrushes and razors."
frequency of breast cancer and prostate cancer
1 in 8 women get breast cancer 1 in 8 men get prostate cancer
The development of a positive HIV antibody test following initial infection generally occurs in which time frame? 8 weeks 10 weeks 4 weeks 6 weeks
4 weeks
Which client is more at risk of becoming infected with human immunodeficiency virus (HIV)? A person having casual intercourse with multiple partners A woman who has had deliveries after the age of 40 A man who uses sildenafil before having intercourse A woman who has never had intercourse
A person having casual intercourse with multiple partners
A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition? A. Lymphedema B. Trousseau's sign C. IV infusion infiltration D. Muscle atrophy
A. Lymphedema Lymphedema is a common postoperative effect of modified radical mastectomy and lymph node dissection. Elevation of the left arm and hand will allow gravity to assist lymph drainage. Other preventive measures include exercises in which the arms are elevated. Trousseau's sign is a sign of hypocalcemia and isn't an expected finding in this situation. IV infusions shouldn't be given in the left arm nor should venipunctures be done in this arm. Although muscle atrophy is a potential adverse effect if the client doesn't exercise her left arm, it wouldn't be prevented by elevation.
Which of the following has been associated with fatigue from cancer chemotherapy? A.Decreased quality of life B.Increased risk of infection C.Improved disease prognosis D.Increased pain
A.Decreased quality of life
When the nurse is teaching the client and family how to manage possible nausea and vomiting at home. Which of the following should be discussed? A.Eating frequent, small meals throughout the day B.Eating three normal meals a day C.Eating only cold foods with no odor D.Limiting the amount of fluid intake
A.Eating frequent, small meals throughout the day
The nurse is teaching a 17 year old client and the clients family about what to expect with high dose chemotherapy and the effects of neutropenia. What should the nurse teach as the most reliable early indicator of infection in a neutropenic client? A.Fever B.Chills C.Tachycardia D.Dyspnea
A.Fever
Which of the following is the most severe form of hypersensitivity reaction? Anaphylaxis Cytotoxic Immune complex Delayed-type
Anaphylaxis
After teaching the parents of a child newly diagnosed with leukemia about the disease, which of the following descriptions given by the mother best indicates that she understands the nature of leukemia? A." The disease is an infection resulting in increased white blood cell production." B."The disease is a type of cancer characterized by an increase in immature white blood cells." C."The disease is an inflammation associated with enlargement of the lymph nodes." D."The disease is an allergic disorder involving increased circulation antibodies in the blood."
B."The disease is a type of cancer characterized by an increase in immature white blood cells."
A 40 year old female is losing most of her hair as a result of chemotherapy. Which of the following statements best explains chemotherapy induced alopecia? A."The new growth of hair will be gray" C."New hair growth will always be the same texture and color as it was before chemotherapy"? D."The client should avoid use of wigs when possible"
B."The hair loss is temporary"
Laboratory findings indicate a child with leukemia is also anemic. The nurse interprets this finding as most likely resulting from which of the following? A.Inadequate dietary folic acid intake B.Decreased red blood cell production C.Increased destruction of red blood cells by lymphocytes D.Progressive replacement of bone marrow with scar tissue
B.Decreased red blood cell production
A 15 year old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which of the following signs and symptoms require the most immediate nursing intervention? A.Fatigue and anorexia B.Fever and petechiae C.Swollen neck lymph glands and lethargy D.Enlarged liver and spleen
B.Fever and petechiae
A 10 year old with leukemia is taking immunosuppressive drugs. The child should: A.Continue with her immunizations B.Not receive any live attenuated vaccines C.Receive vitamin and mineral supplements D.Stay away from her peers
B.Not receive any live attenuated vaccines If immunosuppressed, you can develop severe forms of the disease (measles, mumps rubella, oral polio vaccine if given the live vaccine). Inactivated vaccines may be given if necessary, but the client is not able to adequately produce needed antibodies; it is recommended immunizations be delayed for 3 months after the immunosuppressive drugs have been discontinued.
implications of a positive sentinel node
Before removal of the tumor, radioactive dye is instilled into the tumor bed. During surgery the surrounding lymph nodes are evaluated for the presence of the radioactive dye. The sentinel node is defined as the initial node that drains the tumor bed. The sentinel node is removed and evaluated by pathologist for presence of cancer. Presence of cancer in the sentinel node is an indication that the disease is metastatic at the time of diagnosis; further nodes will be looked at
The patient diagnosed with thrombocytopenia is at risk for which of the following adverse effects: Bleeding Diminished reflexes Headache Stomatitis
Bleeding The patient diagnosed with thrombocytopenia is at risk for bleeding and infection until blood cell counts return to normal. Headache, diminished reflexes, and stomatitis are not adverse effects related to the diagnosis.
The nurse is providing education to a client with cancer radiation treatment options. The nurse determines that the client understands the teaching when the client states that which type of radiation aims to protect healthy tissue during the treatment? Proton therapy External Brachytherapy Teletherapy
Brachytherapy Explanation: In internal radiation, or brachytherapy, a dose of radiation is delivered to a localized area inside the body through the use of an implant. With this type of therapy, the farther the tissue is from the radiation source, the lower the dose. This helps to protect normal tissue from the radiation therapy.
Which of the following statements would the nurse use to describe to the parents why their child with leukemia is at risk for infections? A."Play activities are too strenuous." B."Vitamin C intake is reduced over a period for time." C."The number of red blood cells in inadequate for carrying oxygen." D."Immature white blood cells are incapable of handling an infectious process.
D."Immature white blood cells are incapable of handling an infectious process.
A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which of the following risk factors would the nurse discuss? A.Family history B.Lifestyle choices C.Age D.Menopause or hormonal events
C.Age
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean? Can't assess tumor or regional lymph nodes and no evidence of metastasis Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Explanation: Tis, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.
Other than abstinence, what is the only proven method of decreasing the risk of sexual transmission of HIV infection? Spermicides Vaginal lubricants Consistent and correct use of condoms Birth control pills
Consistent and correct use of condoms
The nurse is obtaining information from a client with Crohn's disease about his medication history. What medication would the nurse include when asking about what medications the client has taken for suppression of the inflammatory and immune response? Diuretics Angiotensin-converting enzyme inhibitors (ACE-I) Corticosteroids Nonsteroidal anti-inflammatory
Corticosteroids
After teaching a child with leukemia scheduled for a bone marrow aspiration about the procedure, the nurse determines the teaching has been successful when the child identifies which of the following as the puncture site? A.Right lateral side of the right wrist. B.Middle of the chest C.Distal end of the thigh D.Back of the hipbone
D.Back of the hipbone
leukemia
Disorder of the blood forming tissue (bone marrow) proliferation of immature WBCs causes: anemis low platelets low WBCs: which opens the patient up to infections: wash hands! no sick visitors treated with chemotherapy acute: Neutrophil count drops quickly ( neutrophil count is high and drops quickly). Low platelet count. Low RBC Chronic: neutrophil count drops slowly (their neutrophils are start out high and slowly drops, neutrophil count will be high unless late leukemia). Platelets high early and low late. RBC low
What is the single most important nursing intervention for a patient with AGC/ANC below 500/cmm?
Handwashing
testing to detect prostate cancer
PSA Digital exam yearly
What post op care following a mastectomy needs to be addressed as well as instructions to Kim given?
Reduce tumor size / and then after to eradicate any remaining cancer cells / she may receive radiation treatment as well •No lifting greater than 10 #'s •Early mobility to avoid complications: DVT, pneumonia etc. •Some swelling is normal. Tightness and tingling across chest is normal; decreased sensation is normal •Report any: any gross swelling or drainage, fever, difficulty breathing, new onset of bleeding, significant increase in vomiting •How to change dressing, care of drains, have patient assist to get use to surgical site look; involve family members as well; assess for infection/healing •Removal of lymph nodes puts her at risk for injury and long term complications such as lymphedema and infection: do no use affected arm for IV's or BP cuff. Compression on the surgical site can cause edema •Elevate the affected arm higher than the shoulder on a pillow but do not abduct it; hand higher than elbow assists with drainage. Encourage ROM & exercises in the affected arm = helps with drainage from lymph system to avoid edema. •May need elastic compression bandage or sleeve to help control swelling even after surgery recovery, in affected arm / lymphedema massage •Adequate nutrition/ high protein •Care of skin if receiving radiation - Avoid deodorant & powders on affected arm until healed •Assess & explore depression and suicidal thoughts; address psychosocial needs: relationships, lifestyle changes, promote healthy body image/ support group = (outcomes, survival increase with )
Kim asks "Why did I get this? Was it something I ate?" You respond with:
Risk factors: •Over age 60/ female •Late onset menopause •Family history of & genetic risk •Menstrual age before 12 •Menopause after age 55 Modifiable •Oral contraceptives/ Hormone replacement therapy more than 5 years •Not having children or having after age 30 •Not breast feeding •Drinking alcohol •Obesity •High fat diet •Physical inactivity Cancer Others: in general: •Diet: • Possibly: Mediterranean diet is protective (fruits and vegetables) : •Avoid eating processed, pickled meats (nitrates)/ BBQ charcoal meat ? still questionable •Age •Alcohol excess •Tanning booths/ excessive exposure to sun with no protection •Cancer causing substances i.e. tobacco / radiation exposure •Hormones •Immunosuppression •Obesity •Infectious agents: viruses etc. •Chronic inflammation
Precision Medicine: treatment for cancer
future therapy, (genetic understanding of the disease (gene therapy/ personalized medicine )
TNM classification
T=size of tumor TX=tumor cannot be measured, T0=no evidence of primary tumor, tis= in situ (pre cancer), T1-4=size of tumor and how much has spread to nearby tissue N=nodes NX = lymph nodes cannot be evaluated, N0= lymph nodes do not contain cancer N1-3= how many lymph are effected, size and location. M= Metastasis M0= has not metastasized M1= metastasized
what is the most common location of breast cancer
UOQ
symptoms of prostate cancer
Urination Issues: •Burning or pain during urination •Difficulty urinating (Dysuria) or trouble starting and stopping while urinating •More frequent urges to urinate at night •Loss of bladder control •Decreased flow or velocity of urine stream •Blood in urine (hematuria) Other: •Prostate cancer may spread (metastasize) to nearby tissues or bones. If the cancer spreads to the spine, it may press on the spinal nerves. Other prostate cancer symptoms include: •Numbness or pain in the hips, legs or feet •Bone pain that doesn't go away, or leads to fractures •Blood in semen •Difficulty getting an erection (erectile dysfunction) •Painful ejaculation •Swelling in legs or pelvic area
care of child with leukemia
allow parents to stay with to reduce stress they think they did something bad and that the illness is a punishment confused why parents can't make it go away
MALIGNANT TUMOR
invasive non cohesive does not stop at tissue boarder invades and destroys surrounding tissue rapid growth metastasizes to distant sites not always easy to remove can recur
BENGIN TUMOR
local well defined boarders cohesive pushes other tissues out of the way slow growth encapsulated easily removed does not recur
Cancer prevention
maintain a healthy weight physical and active lifestyle nutrition should emphasis plant sources
radiation therapy: treatment for cancer
the application of cell-destroying radiation to kill cancerous tissues
Tamoxifen
works by blocking estrogen receptors on breast tissue which inhibits tumor growth and ultimately kills tumor cells; also used to prevent breast CA in high risk individuals
how to perform self breast exams
• need to be done monthly if over 40 yearly mammograms should be done as well Perform day 5-7 after menses •Most breast CA arises in the terminal section of the breast ductal tissue •KNOW WHAT is NORMAL for you •Look in a mirror with shoulders straight and arms on hips, then follow with raised arms to look for any changes:
Stem Cell transplant: treatment for cancer
•(bone marrow, bloodstream, umbilical cord)
Immunotherapy: treatment for cancer
•Help own body fight / cancer cells can thrive because they are able to hide from your immune system •Some: Mark cancer cells: easier for the immune system to find and destroy them. •Boost your immune system to work better against cancer.
Kim wants to know if hospice is needed , " my friend said I should do it now and get more of my bills covered" How do you respond:
•Her condition is still very treatable and is no deemed terminal: explore with therapeutic communication..... is she feeling like she is going to die or does she want to stop chemotherapy treatment and wants to die. •Hospice: MD signs 6 months or less to live; can resign if needed •How it works: a philosophy of care (comfort care) as well as payer of services ( pay for services not available on reg. insurance)/restrictions (cannot pursue active treatment for a cure) •Hospice Facilities: in hospital (floors dedicated to hospice care); group homes; LTC or rehab - can have a hospice nurse and aide visit in patient's own home or with friend/family and services will visit
Hormone Therapy: treatment for cancer
•May lessen the chance that cancer will return /stop /or slow growth./ Make a tumor smaller before surgery or radiation therapy/ called neo-adjuvant therapy. Ease cancer symptoms: i.e. prevent symptoms in men with prostate cancer who are not able to have surgery or radiation therapy.
pt teaching to relieve upset stomach after chemo
•Mouth care before eating •Give a small feeding prior to chemotherapy •Small frequent meals •Administer anti-emetic prior to meal - 30 minutes •Rest period before meal •Avoid sweet, rich, spicy, greasy foods; salty foods may help •Low fat meals with dry foods (toast or crackers) •Sit upright for an hour after meals; eat sitting up as well •Avoid milk & milk products •pepermint sprite
Lab: WBC: 1.2 thou/cmm, Hct 24.9%; Hgb 8.7 g/dl; platelets 25 thou/cmm; differential WBC count shows 37% granulocytes, 60% lymphocytes, 3% monocytes. AGC / ANC is 444/cmm Chem 14: is WNL except: BUN 32 mg/dl Creatinine 1.9 mg/dl What are the probable causes of the abnormal lab findings listed above?
•Myelosuppression from the chemotherapy (kill bone marrow in the blood cell reproductive phases) cause of the decreased WBC, HGB and Hct. •Elevated BUN and creatinine indicate probable dehydration due to N/V and also indicate a developing renal insufficiency (related to chemo drugs) • Low platelet count - probably coming from the side effects of chemotherapy or radiation therapy vs. Breast CA (if leukemia it could be the direct cause) or the cancer may have metastasized to the bone marrow; even possibly DIC (disseminated intravascular coagulation) due to infection/ sepsis
"I've started to lose my hair, what else might I expect with this chemotherapy"? What is your response to Kim?
•Myelosuppression: Reduces WBC = risk infection, (low RBC (anemia)/ may treat with erythropoietin injections (EPO), low platelet = risk for bleeding •Fatigue/ progressive weakness (clients tell us this is a BIG one to deal with) •Exertional dyspnea •Pain: headache/ muscle pain or pain form nerve damage: burning numbness (fingers & toes) •Tachycardia/pallor •Mouth /throat sores •Diarrhea/ nausea & vomiting; possible constipation •Nervous system effects: thinking, memory, loss of balance, shaking or trembling , weakness, neuropathy •Renal dysfunction •Nutrition depletion
"I never did breast self-exams. I want to teach my daughter how to do it right. Can you help teach me?" You respond with what instructions?
•Perform day 5-7 after menses •Most breast CA arises in the terminal section of the breast ductal tissue •KNOW WHAT is NORMAL for you •Look in a mirror with shoulders straight and arms on hips, then follow with raised arms to look for any changes:
chemotherapy treatment for cancer
•stop or slow growth of cancer cells; may be used to ease cancer symptoms; shrink tumors before surgery
Target therapy: treatment for cancer
•targets the changes in cancer cells that help them grow, divide, and spread; can become resistant to them; use with other therapies, such as chemotherapy and radiation. •Stop cancer cells from growing/stop signals that help form blood vessels/deliver cell-killing substances to cancer cells
Warning signs of cancer
⋆Change in bowel or bladder function ⋆A sore that does not heal ⋆Unusual discharge or abnormal bleeding ⋆Thickening or lump in the breast or other tissue ⋆Indigestion or difficulty swallowing ⋆Obvious change in a wart or a mole ⋆Nagging cough or hoarseness CAUTION
The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system? Stem cells Cytokines Lymphoid tissues Red blood cells
Lymphoid tissues
The nurse is aware that the phagocytic immune response, one of the body's responses to invasion, involves the ability of cells to ingest foreign particles. Which of the following engulfs and destroys invading agents? Neutrophils Eosinophils Basophils Macrophages
Macrophages
The nurse performs a breast exam on a client and finds a firm, non-moveable lump in the upper outer quadrant of the right breast that the client reports was not there 3 weeks ago. What does this finding suggest? Malignant tumor with metastasis to surrounding tissue Benign fibrocystic disease Malignant tumor Normal finding
Malignant tumor Explanation: A fast-growing lump is suggestive of a malignant tumor. Metastasis can only be determined by cytology, not by palpation.
Which of the following is the most common HIV-related malignancy? B-cell lymphoma Pancreatic carcinoma Cervical carcinoma Kaposi's sarcoma
Kaposi's sarcoma
A client's most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the client's cancer cells spread? Invasion Angiogenesis Lymphatic circulation Apoptosis
Lymphatic circulation Explanation: Lymph and blood are key mechanisms by which cancer cells spread. Lymphatic spread (the transport of tumor cells through the lymphatic circulation) is the most common mechanism of metastasis. Apoptosis is programmed cellular death.
A patient has enlarged lymph nodes in his neck and a sore throat. This inflammatory response is an example of a cellular immune response whereby: B-lymphocytes respond to a specific antigen Antibodies reside in the plasma Lymphocytes migrate to areas of the lymph node Antibodies are released into the bloodstream
Lymphocytes migrate to areas of the lymph node
A client has discussed therapy for his HIV-positive status. What does the nurse understand is the goal of antiretroviral therapy? Treat mycobacterium avium complex. Eliminate the risk of AIDS. Bring the viral load to a virtually undetectable level Reverse the HIV+ status to a negative status.
Bring the viral load to a virtually undetectable level
A nurse provides care on a bone marrow transplant unit and is preparing a female client for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the client's family and friends? "Your family should likely gather at the bedside in case there's a negative outcome." "Do not visit if you've had a recent infection." "Make sure she doesn't eat any food in the 24 hours before the procedure." "Wear a hospital gown when you go into the client's room."
"Do not visit if you've had a recent infection." Explanation: Before HSCT, clients are at a high risk for infection, sepsis, and bleeding. Visitors should not visit if they have had a recent illness or vaccination. Gowns should indeed be worn, but this is secondary in importance to avoiding the client's contact with ill visitors. Prolonged fasting is unnecessary. Negative outcomes are possible, but the procedure would not normally be so risky as to require the family to gather at the bedside.
A 16-year-old has come to the clinic and asks to talk to a nurse. The teen states that she has become sexually active and is concerned about getting HIV. The teen asks the nurse what she can do to keep from getting HIV. What would be the nurse's best response? "Only the correct use of a female condom protects against the transmission of HIV." "Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV." "There's no way to be sure you won't get HIV except to use condoms correctly." "There are new ways of protecting yourself from HIV that are being discovered every day."
"Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV."
The clinic nurse is caring for a patient whose grandmother and sister have both had breast cancer. She requested a screening test to determine her risk of developing breast cancer and it has come back positive. The patient asks you what she can do to help prevent breast cancer from occurring. What would be your best response? "Research has shown that eating a healthy diet can provide all the protection you need against breast cancer." "Research has shown that there is little you can do to reduce your risk of breast cancer if you have a genetic predisposition." "Research has shown that exercising at least 30 minutes every day can reduce your chance of breast cancer." "Research has shown that taking the drug tamoxifen can reduce your chance of breast cancer."
"Research has shown that taking the drug tamoxifen can reduce your chance of breast cancer." Explanation: Large-scale breast cancer prevention studies supported by the National Cancer Institute (NCI) indicated that chemoprevention with the medication tamoxifen can reduce the incidence of breast cancer by 50% in women at high risk for breast cancer. A healthy diet and regular exercise are important, but not wholly sufficient preventive measures.
A client is informed that his white blood cell count is low and that he is at risk for the development of infections. The client asks, "Where do I make new white blood cells?" What is the best response by the nurse? "White blood cells are produced in the lymphatic tissue." "White blood cells are produced in the plasma." "White blood cells are produced in the bone marrow." "White blood cells are produced in the thymus gland."
"White blood cells are produced in the bone marrow."
An oncology nurse is contributing to the care of a client who has failed to respond appreciably to conventional cancer treatments. As a result, the care team is considering the possible use of biologic response modifiers (BRMs). The nurse should know that these achieve a therapeutic effect by what means? Potentiating the effects of chemotherapeutic agents and radiation therapy Promoting the synthesis and release of leukocytes Altering the immunologic relationship between the tumor and the client Focusing the client's immune system exclusively on the tumor
Altering the immunologic relationship between the tumor and the client Explanation: BRMs alter the immunologic relationship between the tumor and the cancer client (host) to provide a therapeutic benefit. They do not necessarily increase white cell production or focus the immune system solely on the tumor. BRMs do not potentiate radiotherapy and chemotherapy.
While being educated by the nurse about breast self-examination, a client asks wheat the rationale is for moving her arms in different positions while standing in front of a mirror. The nurse explains these positions are use to: A.Increase the examiner's comfort during procedure B.More easily diagnose any masses C.Determine whether there is any nipple discharge with movement D.Emphasize any change in shape or contour of the breast
Emphasize any change in shape or contour of the breast
A side-effect of chemotherapy is renal damage. To prevent this, the nurse should: Modify the diet to acidify the urine, thus preventing uric acid crystallization. Withhold medication when the blood urea nitrogen level exceeds 20 mg/dL. Encourage fluid intake, if possible, to dilute the urine. Limit fluids to 1,000 mL/day to minimize stress on the renal tubules.
Encourage fluid intake, if possible, to dilute the urine. Explanation: To prevent renal damage, it is helpful to dilute the urine by increasing fluids as tolerated.
When the client complains of increased fatigue following radiotherapy, the nurse knows this is most likely to be related to which factor? Radiation can result in myelosuppression. Fighting off infection is an exhausting venture. The cancer cells are dying in large numbers. The cancer is spreading.
Radiation can result in myelosuppression. Explanation: Fatigue results from anemia associated with myelosuppression and decreased RBC production. The spreading of cancer can cause many symptoms dependent on location and type of cancer but not a significant factor to support fatigue with radiotherapy. The production of healthy cells can increase metabolic rate, but death of cancer cells does not support fatigue in this case. Fighting infection can cause fatigue, but there is no evidence provided to support presence of infection in this client.
What are the primary participants in the immune system? Lymphoblasts and gamma globulins T- and B- cell lymphocytes Macrophages and memory cells Stem cells and monocytes
T- and B- cell lymphocytes
What types of cells are the primary targets of the healthy immune system? Select all that apply. foreign cells typical cells infectious cells cancerous cells
foreign cells infectious cells cancerous cells
A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of: capillaries. cytoblasts. antibodies. lymphocytes.
lymphocytes.
A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions? Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens. It is only necessary to use gloves when you are emptying reservoirs that have body fluids in them. If you are careful and do not expose yourself to blood or body fluids, it is not necessary to use gloves all of the time. Standard precautions should only be used with patients who are HIV positive to reduce the risk of transmission of the HIV virus.
Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens.
A public health nurse is giving an informational presentation on HIV/AIDS at a nearby college. How would the nurse best define AIDS? Acquired immunodeficiency syndrome (AIDS) is an infectious and potentially life-threatening disease that severely compromises the immune system. Acquired immunodeficiency syndrome is an infectious disease transmitted in blood and body fluids. Acquired immunodeficiency syndrome is a potentially life-threatening infection that profoundly weakens the immune system. Acquired immunodeficiency syndrome is a sexually transmitted disease.
Acquired mmunodeficiency syndrome (AIDS) is an infectious and potentially life-threatening disease that severely compromises the immune system.
While visiting the pediatric clinic, a parent picks up a brochure about immunizations and asks about active and passive acquired immunity to childhood diseases. What is the best explanation by the nurse? Active acquired immunity, because the person develops defenses in response to a disease Active acquired immunity, because the person's own body develops defenses Passive acquired immunity, because the defenses are given to the person in the form of an immunization Passive acquired immunity, because the defenses are developed from a substance given to the person
Active acquired immunity, because the person's own body develops defenses
A gardener sustained a deep laceration while working and requires sutures. The date of the client's last tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus immunization which will allow for the release of what? Antigens Phagocytes Antibodies Cytokines
Antibodies
A client will be receiving a hepatitis B vaccination series prior to employment in a dialysis center. What type of immunity will this provide? Forced immunity Naturally acquired active immunity Artificially acquired active immunity Passive immunity
Artificially acquired active immunity
A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia? Perform a cardiovascular assessment every 4 hours. Check the client's history for a congenital link to thrombocytopenia. Closely observe the client's skin for petechiae and bruising. Monitor daily platelet counts.
Closely observe the client's skin for petechiae and bruising. Explanation: The nurse should closely observe the client's skin for petechiae and bruising. Daily laboratory testing may not reflect the client's condition as quickly as subtle changes in the client's skin. Performing a cardiovascular assessment every 4 hours and checking the clients history for a congenital link to thrombocytopenia don't help detect early signs and symptoms of thrombocytopenia.
Which of the following is a age-related change associated with the immune system? Elevated phagocytic immune response Increased antibody production Ability to differentiate "self" from "nonself" Decreased antibody production
Decreased antibody production
The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA). Such damage results from multiple factors. Which of the following is a carcinogen? Medically prescribed interventions Dietary substances Defective genes Chemical agents Environmental factors Viruses
Dietary substances Environmental factors Viruses Chemical agents Defective genes Medically prescribed interventions Explanation: Carcinogens include chemical agents, environmental factors, dietary substances, viruses, defective genes, and medically prescribed interventions.
A client asks a nurse, "What can I use to decrease my risk of exposure to HIV?" What will the nurse include as effective in reducing the risk of HIV exposure? Select all that apply. Polyurethane female condoms Sexual abstinence Lambskin condoms Latex male condoms Dental dams
Polyurethane female condoms Sexual abstinence Latex male condoms Dental dams
A school nurse is talking about infection with a high school health class. What would be the nurse's best explanation of the process of phagocytosis? Release of chemicals to destroy bacteria and foreign material Conversion of memory cells to plasma cells Removal of bacteria and dead blood cells from circulation Engulfment and digestion of bacteria and foreign material
Engulfment and digestion of bacteria and foreign material
A decrease in circulating white blood cells (WBCs) is referred to as Leukopenia Thrombocytopenia Neutropenia Granulocytopenia
Leukopenia Explanation: A decrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count.
A nurse who works in an oncology clinic is assessing a client who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the client's skin appears yellow. Which blood tests should be done to further explore this clinical sign? Liver function tests (LFTs) Blood urea nitrogen and creatinine Complete blood count (CBC) Platelet count
Liver function tests (LFTs)
A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurse's choice of educational interventions? Older adults tend to have more sex partners than younger adults. Many older adults are not aware of the difference between HIV and AIDS. Many older adults do not see themselves as being at risk for HIV infection. Older adults have the highest incidence of intravenous drug use.
Many older adults do not see themselves as being at risk for HIV infection.
Kim has now received 3 cycles of CAF . Her last treatment was 11 days ago. She presents at the ED with a 2 day history of chills, fever and SOB, She is agitated and disoriented. V/S: BP-87/44, H.R. 119, Temp: 39.8C, Sao2 85% on room air Lab: WBC: 1.2 thou/cmm, Hct 24.9%; Hgb 8.7 g/dl; platelets 25 thou/cmm; differential WBC count shows 37% granulocytes, 60% lymphocytes, 3% monocytes. AGC / ANC is 444/cmm Chem 14: is WNL except: BUN 32 mg/dl Creatinine 1.9 mg/dl. Chest x-ray shows diffuse infiltrates in the left lower lung What is the purpose of her chemotherapy? What lab results put Kim at a risk for infection & bleeding
Purpose: If receiving prior to surgery: to shrink tumor before her mastectomy surgery; following surgery: kill any remaining cancer cells. •WBC low, AGC / ANC (absolute neutrophil count is below 500 so risk is severe) ANC is a measure of the number of neutrophils; it is low. These are your infection fighting white blood cells in your body; High risk for infection - can go septic fast. •Low platelet count will put her at risk for bleeding: monitor for black tarry stool, coffee ground emesis, bruising; teach to avoid falls etc. safety precautions •Anemia: low RBC's: symptoms: fatigue, dizziness, SOB •Chemotherapy affects bone marrows ability to make new blood cells.
The nurse is describing some of the major characteristics of cancer to a client who has recently received a diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse should explain differences in which of the following aspects? Select all that apply. Rate of growth Ability to spread Ability to cause death Size of cells Cell contents
Rate of growth Ability to cause death Ability to spread Explanation: Benign and malignant cells differ in many cellular growth characteristics, including the method and rate of growth, ability to metastasize or spread, general effects, destruction of tissue, and ability to cause death. Cells come in many sizes, both benign and malignant. Cell contents are basically the same, but they behave differently.
At a public health fair, a nurse teaches a group of women about breast cancer awareness. Possible signs of breast cancer include: fever. fever and erythema of the breast. breast changes during menstruation. nipple discharge and a breast nodule.
nipple discharge and a breast nodule. Explanation: Nipple discharge, breast nodules, nipple retraction, and lymphadenopathy may be signs of breast cancer and should be reported. Mammary duct ectasia may cause fever, nipple discharge, breast nodules, erythema of the breast, and itching. Breast changes during menstruation are normal; for this reason, women should examine their breasts 4 to 7 days after menses ends, when the breasts are least congested. Fever and erythema of the breast may indicate a breast abscess.
An oncologist advises a client with an extensive family history of breast cancer to consider a mastectomy. What type of surgery would the nurse include in teaching? palliative prophylactic cryoablation local excision
prophylactic Explanation: Also called preventive surgery, prophylactic surgery may be done when there is a family history or genetic predisposition, ability to detect cancer at an early stage, and client acceptance of the postoperative outcome. Local excision is done when an existing tumor is removed along with a small margin of healthy tissue. Palliative surgery relieves symptoms. Cryoablation uses cold to destroy cancerous cells.
Palliation refers to relief of symptoms of disease and promotion of comfort and quality of life. the lowest point of white blood cell depression after therapy that has toxic effects on bone marrow. hair loss. the spread of cancer cells from the primary tumor to distant sites.
relief of symptoms of disease and promotion of comfort and quality of life.
Surgery / Freeze: Treatment of Cancer
•(cryotherapy & Cryoblation) / Electrosurgery/ Laser / photodynamic (light sensitizing agent injected and exposed to laser light), RFA radiofrequency causes heat)
The nurse is caring for a client who has just been given a 6-month prognosis following a diagnosis of extensive stage small-cell lung cancer. The client states that he would like to die at home, but the team believes that the client's care needs are unable to be met in a home environment. What might the nurse suggest as an alternative? Panel the client for a personal care home. Discuss a referral for rehabilitation hospital. Discuss a referral for hospice care. Discuss a referral for acute care.
Discuss a referral for hospice care. Explanation: Hospice care can be provided in several settings. Because of the high cost associated with free-standing hospices, care is often delivered by coordinating services provided by both hospitals and the community. The primary goal of hospice care is to provide support to the client and family. Clients who are referred to hospice care generally have fewer than 6 months to live. Each of the other listed options would be less appropriate for the client's physical and psychosocial needs.
A patient with uterine cancer is being treated with internal radiation therapy. What would the nurse's priority responsibility be for this patient? Alert family members that they should restrict their visiting to 5 minutes at any one time. Maintain as much distance as possible from the patient while in the room. Explain to the patient that she will continue to emit radiation while the implant is in place. Wear a lead apron when providing direct patient care.
Explain to the patient that she will continue to emit radiation while the implant is in place. Explanation: When the patient has a radioactive implant in place, the nurse and other health care providers need to protect themselves, as well as the patient, from the effects of radiation. Patients receiving internal radiation emit radiation while the implant is in place; therefore, contact with the health care team is guided by principles of time, distance, and shielding to minimize exposure of personnel to radiation. Safety precautions used in caring for a patient receiving brachytherapy include assigning the patient to a private room, posting appropriate notices about radiation safety precautions, having staff members wear dosimeter badges, making sure that pregnant staff members are not assigned to the patient's care, prohibiting visits by children or pregnant visitors, limiting visits from others to 30 minutes daily, and seeing that visitors maintain a 6-foot distance from the radiation source.
The nurse is assessing the diet of a female client. To decrease the risk of cancer in general, the nurse instructs the client to Decrease cigarette smoking from one pack/day to 1/2 pack/day. Include at least 6 ounces of meat in meals every day. Ingest two to three servings of fruits and vegetables each day. Limit alcohol ingestion to one drink per day.
Limit alcohol ingestion to one drink per day. Explanation: Alcohol increases the risks of certain cancers and should be limited to no more than one drink per day for women. Smoking is strongly associated with certain cancers, and tobacco may act synergistically with other substances. Even decreasing use of tobacco still places one at risk for cancer. Recommendation by the U.S. Department of Agriculture for fruits and vegetables is 4 1/2 cups per day and for protein is 5 1/2 ounces per day with low-fat or lean meat and poultry and/or other proteins such as fish, beans, peas, nuts, and seeds.
A client newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe? Nausea and vomiting Confusion Altered glucose metabolism Pruritis (itching)
Nausea and vomiting
A 20-year-old client cut a hand while replacing a window. While reviewing the complete blood count (CBC) with differential, the nurse would expect which cell type to be elevated first in an attempt to prevent infection in the client's hand? Monocytes Neutrophils Eosinophils B cells
Neutrophils
An important nursing function is monitoring factors that may indicate that bleeding is occurring. One serum indicator is a (an): Reticulocyte count of 1%. Lymphocyte count of 30%. Neutrophil count of 60%. Platelet count of 60,000/mm3.
Platelet count of 60,000/mm3. Explanation: Thrombocytopenia, a decrease in the circulating platelet count, is the most common cause of bleeding in patients with cancer and is usually defined as a count less than 100,000/mm3. The risk of bleeding increases as the count drops lower. The risk of spontaneous bleeding occurs with a count of less than 20,000/mm3.
A client with Crohn's disease, an autoimmune disorder, informs the nurse that he has not had any symptoms of the disease in 8 months. What does the nurse understand this asymptomatic period is referred to? An acute inflammatory response Remission An exacerbation A cure
Remission
After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, which nursing diagnosis takes priority? Risk for infection Risk for injury Anxiety Imbalanced nutrition: Less than body requirements
Risk for infection Explanation: Risk for infection takes highest priority in clients with severe bone marrow depression because they have a decrease in the number of white blood cells, the cells that fight infection. Making clients aware that they are at risk for injuries can help prevent such injuries as falls. The nurse should institute the facility's falls prevention protocol and supply assistive devices, such as a walker, cane, or wheelchair, when needed. Imbalanced nutrition: Less than body requirements is also of concern but doesn't take priority over preventing infection. Anxiety is likely present in clients with severe bone marrow depression; however, anxiety doesn't take priority over preventing infection.
A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client? Provide a urinal or bedpan to decrease the likelihood of soiling linens. Wear sterile gloves. Wear personal protective equipment when handling blood, body fluids, and feces. Place incontinence pads in the regular trash container.
Wear personal protective equipment when handling blood, body fluids, and feces. Chemotherapy drugs are present in the waste and body fluids of clients for 48 hours after administration. The nurse should wear personal protective equipment when handling blood, body fluids, or feces. Gloves offer minimal protection against exposure. The nurse should wear a face shield, gown, and gloves when exposure to blood or body fluid is likely. Placing incontinence pads in the regular trash container and providing a urinal or bedpan don't protect the nurse caring for the client.
A nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women: perform breast self-examination annually. have a mammogram annually. have a physician conduct a clinical examination every 2 years. have a hormonal receptor assay annually.
have a mammogram annually. Explanation: The American Cancer Society guidelines state that women age 40 and older should have a mammogram annually and a clinical examination at least annually (not every 2 years). All women should perform breast self-examination monthly (not annually). The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse? "I.V. drug users can get HIV from sharing needles." "I've heard about people who got AIDS from blood transfusions." "I won't donate blood because I don't want to get AIDS." "A man should wear a latex condom during intimate sexual contact."
"I won't donate blood because I don't want to get AIDS."
The clinic nurse is caring for a client who has just been diagnosed with a tumor. The client says to the nurse "The doctor says my tumor is benign. What does that mean?" What is the nurse's best response? "Benign tumors invade surrounding tissue." "Benign tumors grow very rapidly." "Benign tumors don't usually cause death." "Benign tumors can spread from one place to another."
"Benign tumors don't usually cause death." Explanation: Benign tumors remain at their site of development. They may grow large, but their growth rate is slower than that of malignant tumors. They usually do not cause death unless their location impairs the function of a vital organ, such as the brain.
A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse? "If you don't have the blood transfusions, you may not make it through this episode of bleeding." "I understand what you mean, you can never be sure if the blood is tainted." "I understand your concern. The blood is screened very carefully for different viruses as well as HIV." "No one has gotten HIV from blood in a long time. You have to have the transfusion."
"I understand your concern. The blood is screened very carefully for different viruses as well as HIV."
The nurse is instructing a male client about safer sexual behaviors. Which client statement indicates a need for additional instruction? "I should use a new condom each time I have sex." "After having sex, I should hold onto the condom when pulling out." "I will apply baby oil to lubricate the condom." "My partner and I should avoid manual-anal intercourse."
"I will apply baby oil to lubricate the condom."
A client with advanced cancer makes the following comment to the nurse: "Why are you bathing me? I am going to die no matter what." What is the most appropriate response of the nurse? "A bath will make you feel better." "Do you want to skip the bath today?" "Would you like to talk about what you are feeling?" "I can give you some medicine to make you feel better."
"Would you like to talk about what you are feeling?"
The following lesions found on an AIDS patient would be linked to what condition: A.Kaposi's Sarcoma B.Herpes Simplex C.Varicella D.ITP
A.Kaposi's Sarcoma •KS (Kaposi's Sarcoma) is considered an "AIDS defining" illness. This means that when KS occurs in someone infected with HIV, that person officially has AIDS (and is not just HIV-positive). •A neoplasm/The abnormal cells of KS form purple, red, or brown blotches or tumors on the skin. These affected areas are called lesions. The skin lesions of KS most often appear on the legs or face. They may look bad, but they usually cause no symptoms. Some lesions on the legs or in the groin area may cause the legs and feet to swell painfully. •KS can cause serious problems or even become life threatening when the lesions are in the lungs, liver, or digestive tract. KS in the digestive tract, for example, can cause bleeding, while tumors in the lungs may cause trouble breathing.
A nurse has given a child's scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following? Cellular immunity Natural immunity Active acquired immunity Mild hypersensitivity
Active acquired immunity
The nurse is caring for a client whose most recent laboratory values reveal a neutrophil level of 21,000 mm3. When preparing to assess the client, the nurse should prioritize what assessment? Assessing the client's activity level and functional status Assessing the client for signs of venous thromboembolism Assessing the client for indications of internal or external hemorrhage Assessing the client for signs and symptoms of infection
Assessing the client for signs and symptoms of infection
Which type of vaccine uses the client's own cancer cells, which are killed and prepared for injection back into the client? Prophylactic Therapeutic Allogeneic Autologous
Autologous Explanation: Autologous vaccines are made from the client's own cancer cells, which are obtained during diagnostic biopsy or surgery. Prophylactic vaccines, such as the polio vaccine, are given to prevent people from developing a disease. Therapeutic vaccines are given to kill existing cancer cells and to provide long-lasting immunity against further cancer development. Allogeneic vaccines are made from cancer cells that are obtained from other people who have a specific type of cancer.
The nurse is caring for a client who has just had a radical mastectomy and axillary node dissection. When providing client education regarding rehabilitation, what should the nurse recommend? Avoid exercise of the arm for the next 2 months. Keep cuticles clipped neatly. Use a sling until healing is complete. Avoid lifting objects heavier than 10 pounds (4.5 kg).
Avoid lifting objects heavier than 10 pounds (4.5 kg). Explanation: Following an axillary dissection, the client should avoid lifting objects greater than 5 to 10 pounds, cutting the cuticles, and undergoing venipuncture on the affected side. Exercises of the hand and arm are encouraged and the use of a sling is not necessary.
The nurse is evaluating bloodwork results of a client with cancer who is receiving chemotherapy. The client's platelet count is 60,000/mm3. Which is an appropriate nursing action? Taking the client's temperature rectally Providing commercial mouthwash to the client Avoiding the use of products containing aspirin Providing a razor so the client can shave
Avoiding the use of products containing aspirin Explanation: Clients with a platelet count of 60,000/mm3 are at mild risk for bleeding. Appropriate nursing interventions include avoiding the use of products such as aspirin that may interfere with the client's clotting systems; avoiding taking temperature rectally and administering suppositories; providing the client with an electric shaver for shaving; and avoiding commercial mouthwashes because of their potential to dry out oral mucosa, which can lead to cracking and bleeding.
A client at the walk-in clinic reports exposure to human immunodeficiency virus (HIV). The client wants to know the precise sources through which the HIV infection is transmitted. What is the nurse's best response? Semen Urine Saliva Sweat
Semen
You are the nurse caring for a client with cancer. The client complains of pain and nausea. When assessed, you note that the client appears fearful. What other factor must you consider when a client with cancer indicates signs of pain, nausea, and fear? High cholesterol levels Fatigue Infection Ulceration
Fatigue Explanation: Clients with cancer experience fatigue, which is a side effect of cancer treatments that rest fails to relieve. The nurse must assess the client for other stressors that contribute to fatigue such as pain, nausea, fear, and lack of adequate support. The nurse works with other healthcare team members to treat the client's fatigue. The above indications do not contribute to infections, ulcerations, or high cholesterol levels.
The nurse is admitting an oncology client to the unit prior to surgery. The nurse reads in the electronic health record that the client has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem? Cognitive deficits Impaired wound healing Tumor lysis syndrome Cardiac tamponade
Impaired wound healing Explanation: Combining other treatment methods, such as radiation and chemotherapy, with surgery contributes to postoperative complications, such as infection, impaired wound healing, altered pulmonary or renal function, and the development of deep vein thrombosis. Cardiac tamponade, cognitive effects, and tumor lysis syndrome are less commonly associated with combination therapy.
A client tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous? Nonmobile mass with irregular edges Eversion of the right nipple and mobile mass Mobile mass that is soft and easily delineated Nonpalpable right axillary lymph nodes
Nonmobile mass with irregular edges Explanation: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer.
A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have? There is no immunity passed down from mother to child. Passive immunity transferred by the mother Artificially acquired active immunity Naturally acquired active immunity
Passive immunity transferred by the mother
A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of what? Phagocytic cells Interferons Cytokines Apoptosis
Phagocytic cells
A client is admitted with cellulitis and experiences a consequent increase in white blood cell count. During what process will pathogens be engulfed by white blood cells that ingest foreign particles? Cellular immune response Antibody response Phagocytosis Apoptosis
Phagocytosis
A male client has been unable to return to work for 10 days following chemotherapy as the result of ongoing fatigue and inability to perform usual activities. Laboratory test results are WBCs 2000/mm³, RBCs 3.2 x 10¹²/L, and platelets 85,000/mm³. The nurse notes that the client is anxious. Which of the following is the priority nursing diagnosis? Fatigue related to deficient blood cells Activity intolerance related to side effects of chemotherapy Anxiety related to change in role function Risk for infection related to inadequate defenses
Risk for infection related to inadequate defenses Explanation: Physiological needs, such as risk for infection, take priority over the client's other needs.
The nurse is caring for a client with a benign breast tumor. The tumor may have which characteristic? Slow rate of growth Causes generalized symptoms Ability to invade other tissues Undifferentiated cells
Slow rate of growth Explanation: Benign tumors have a slow rate of growth and well-differentiated cells. Benign tumors do not invade surrounding tissue and do not cause generalized symptoms unless the location of the tumor interferes with the functioning of vital organs.
The nurse is caring for an older client admitted to the health-care facility with a new onset of confusion and a low-grade fever. Which age-related changes might contribute to decreased functioning of the immune system? Increased ciliary action Increased gastric secretions Decreased kidney function Thickening of the skin
T- and B- cell lymphocytes
The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What actions would the instructor explain occur in a cell-mediated response? The invading antigens precipitate. The invading antigens link together (agglutination). Toxins of invading antigens are neutralized. T-cell lymphocytes survey proteins in the body and attack the invading antigens.
T-cell lymphocytes survey proteins in the body and attack the invading antigens.
A client has received the results of a HIV antibody test, which is positive. What is the best explanation for the nurse to give to the client? The antibodies indicate immunity. The HIV infection confirms the presence of AIDS. The client cannot transmit the virus to others. The client has been infected and has produced antibodies.
The client has been infected and has produced antibodies.
The nurse is assessing a client's risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity? The client takes a beta blocker for the treatment of hypertension. The client is under significant psychosocial stress. The client had a pulmonary embolism 18 months ago. The client has a family history of breast cancer.
The client is under significant psychosocial stress.
A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the client's skin test for TB is negative if the client's physician has diagnosed TB. The nurse's correct reply is which of the following? The client has only mild TB, which is not enough to cause a reaction. The skin test was improperly performed. The solution used for the skin test was probably outdated. The client's immune system cannot mount a response to the skin test.
The client's immune system cannot mount a response to the skin test.
Why would it be important for the nurse to question the client about sexual practices, history of substance abuse, and his lifestyle during the interview process? To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS) To determine if the client needs a referral to counseling services To determine what type of personality the client has To find out if the client will be compliant with therapeutic treatments
To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS)
What is the most common location for breast cancer? Upper outer quadrant of the breast Upper inner quadrant of the breast Nipple-areola complex Lower half of the breast
Upper outer quadrant of the breast Explanation: Most breast cancers are found in the upper outer quadrant of the breast, where most breast tissues are located.
What is the best way for the nurse to assess the nutritional status of a patient with cancer? Weigh the patient daily. Assess BUN and creatinine levels. Monitor daily caloric intake. Observe for proper wound healing.
Weigh the patient daily. Explanation: Assessment of the patient's nutritional status is conducted at diagnosis and monitored throughout the course of treatment and follow-up. Early identification of patients at risk for problems with intake, absorption, and cachexia, particularly during the early stages of disease, can facilitate timely implementation of specifically targeted interventions that attempt to improve quality of life, treatment outcomes, and survival. Current weight, weight loss, diet and medication history, patterns of anorexia, nausea and vomiting, and situations and foods that aggravate or relieve symptoms are assessed and addressed.
Which of the following would be inconsistent as a common side effect of chemotherapy? Alopecia Weight gain Myelosuppression Fatigue
Weight gain Explanation: Common side effects seen with chemotherapy include myelosuppression, alopecia, nausea and vomiting, anorexia, and fatigue.
A nurse is teaching a group of women about the potential benefits of breast self-examination (BSE). The nurse should teach the women that effective BSE is dependent on what factor? Women's knowledge of the pathophysiology of breast cancer The rapport that exists between the woman and her primary care provider Women's knowledge of how their breasts normally look and feel Synchronizing women's routines around BSE with the performance of mammograms
Women's knowledge of how their breasts normally look and feel Explanation: Current practice emphasizes the importance of breast self-awareness, which is a woman's attentiveness to the normal appearance and feel of her breasts. BSE does not need to be synchronized with the performance of mammograms. Rapport between the client and the care provider is beneficial, but does not necessarily determine the effectiveness of BSE. The woman does not need to understand the pathophysiology of breast cancer to perform BSE effectively.
