Med SRUG 4
A client with Hodgkin lymphoma is receiving information from the oncology nurse. The client asks the nurse why it is necessary to stop drinking and smoking and stay out of the sun. What would be the nurse's best response?
"It's important to reduce other factors that increase the risk of second cancers." Explanation: The nurse should encourage clients to reduce other factors that increase the risk of developing second cancers, such as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight. The other options do not answer the client's question, and also make light of the client's question.
A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." "OA originates with an infection. RA is a result of your body's cells attacking one another." "OA is associated with impaired immune function; RA is a consequence of physical damage."
"OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Explanation: OA is a degenerative arthritis with a noninflammatory etiology, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints, with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. The diseases are not distinguished by the joints affected and neither has an infectious etiology. Reference:
A client with acute kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results? You Selected:
A decreased hemoglobin and hematocrit Explanation: The decreased production of erythropoietin will result in a decreased hemoglobin and hematocrit. The client will have normal MCV and RDW because the erythrocytes are normal in appearance.
A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is:
Albumin. Explanation: Albumin, only produced in the liver, is essential for maintaining oncotic pressure in the vascular system. A decrease in oncotic pressure due to low albumin causes fluid to leak into the peritoneal cavity.
A client is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which procedure will be involved? `` Angiography Myelography Paracentesis Arthrocentesis
Arthrocentesis Explanation: Arthrocentesis involves needle aspiration of synovial fluid. Angiography is an x-ray study of circulation with a contrast agent injected into a selected artery. Myelography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Paracentesis is removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal wall under sterile conditions.
A client with advanced leukemia is responding poorly to treatment. The nurse finds the client tearful and trying to express feelings, but he is clearly having difficulty. What is the nurse's most appropriate action?
Ask if the client would like the nurse to sit with him while he collects thoughts.
After receiving a diagnosis of acute lymphocytic leukemia, a client is visibly distraught, stating, "I have no idea where to go from here." How should the nurse prepare to meet this client's psychosocial needs?
Assess the client's specific needs for education and support.
When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend?
Avoiding cold temperatures and ensuring sufficient hydration Explanation: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximising activity may exacerbate pain and be unrealistic.
A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores?
Beef liver accompanied by orange juice
nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? Petechiae Butterfly rash Jaundice Skin sloughing
Butterfly rash Explanation: An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks occurs in SLE. Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE. Clients with SLE do not typically experience jaundice or skin sloughing. Reference:
A client with leukemia has developed stomatitis and is experiencing a nutritional deficit. An oral anesthetic has consequently been prescribed. What health education should the nurse provide to the client?
Chew with care to avoid inadvertently biting the tongue.
A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase her daily intake of what substance?
Correct response: Iron Explanation: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased.
A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the disease. What potential etiology should the nurse explain to this client?
Decreased production of platelets.
A client on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action?
Discontinue the remainder of the PRBC transfusion and inform the health care provider. Explanation: Because of the risk of infection, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route. `
client with poorly controlled diabetes has developed end-stage kidney injury and consequent anemia. When reviewing this client's treatment plan, the nurse should anticipate the use of what drug?
Epoetin alfa Explanation: The anemia that accompanies end-stage kidney injury is caused by decreased synthesis of erythropoietin. Exogenous forms are necessary to stimulate erythropoiesis. Heparin, vitamin K, and magnesium are not indicated in the treatment of kidney injury or the consequent anemia.
An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status?
Fatigue related to decreased oxygen-carrying capacity Explanation: Fatigue is the major assessment finding common to all forms of anemia. Anemia does not normally result in acute pain or fluid deficit. The client may have an increased risk of infection due to impaired immune function, but fatigue is more likely.
A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host?
Graft-versus-host disease
The nurse is describing normal RBC physiology to a client who has a diagnosis of anemia. The nurse should explain that the RBCs consist primarily of which of the following?
Hemoglobin Explanation: Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. RBCs are not made of fibrin or plasminogen. Hematocrit is a measure of RBC volume in whole blood.
An oncology nurse is caring for a client with multiple myeloma who is experiencing bone destruction. When reviewing the client's most recent blood tests, the nurse should anticipate what imbalance?
Hypercalcemia
A client with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where?
In the bone marrow
clinic nurse is caring for a client with suspected gout. While explaining the pathophysiology of gout to the client, what should the nurse explain? Autoimmune processes in the joints Chronic metabolic acidosis Increased uric acid levels Unstable serum calcium levels
Increased uric acid levels Explanation: Gout is caused by hyperuricemia (increased serum uric acid). Gout is not categorized as an autoimmune disease and it does not result from metabolic acidosis or unstable serum calcium levels.
nurse is planning the care of a client who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. What nursing diagnosis is most likely to apply to this woman's care needs? Ineffective Role Performance Related to Pain Risk for Impaired Skin Integrity Related to Myalgia Risk for Infection Related to Tissue Alterations Unilateral Neglect Related to Neuropathic Pain
Ineffective Role Performance Related to Pain Explanation: Typically, clients with fibromyalgia have endured their symptoms for a long period of time. The neuropathic pain accompanying FM can often impair a client's ability to perform normal roles and functions. Skin integrity is unaffected and the disease has no associated infection risk. Activity limitations may result in neglect, but not of a unilateral nature.
The nurse on the pediatric unit is caring for a 10-year-old boy with a diagnosis of hemophilia. The nurse should assess carefully for indication of what nursing diagnosis?
Ineffective coping Explanation: Most clients with hemophilia are diagnosed as children. They often require assistance in coping with the condition because it is chronic, places restrictions on their lives, and is an inherited disorder that can be passed to future generations. Children with hemophilia are not at risk of hypothermia, diarrhea, or imbalanced nutrition.
A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the client's plan of care? You Selected: Ineffective tissue perfusion related to thrombosis
Ineffective tissue perfusion related to thrombosis Explanation: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis.
A client comes to the clinic reporting fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the client will be diagnosed?
Iron deficiency anemia Explanation: A low serum iron level, a low ferritin level, and symptoms of pica are associated with iron deficiency anemia. TIBC may also be elevated. None of the other anemias are associated with pica.
A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?
Iron will cause the stools to darken in color. Explanation: The nurse will inform the client that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Clients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy.
A 63-year-old woman has been diagnosed with polycythemia vera (PV) after undergoing a series of diagnostic tests. When the woman's nurse is providing health education, what subject should the nurse prioritize? Maintenance of long-term vascular access device Nutritional modifications necessary for maintaining a low-iron diet Strategies for managing activity Lifestyle modifications and techniques for preventing thromboembolism
Lifestyle modifications and techniques for preventing thromboembolism Explanation: The increased blood volume and viscosity that are the hallmarks of PV create a significant risk of thromboembolism. A vascular access device is not necessary for the treatment of PV, and a low-iron diet does not resolve the disease. Patients may experience fatigue, but this risk is superseded by that of thromboembolism.
A nurse is creating a teaching plan for a client who has a recent diagnosis of scleroderma. What topics should the nurse address during health education? Select all that apply. Surgical treatment options The importance of weight loss Managing Raynaud-type symptoms Smoking cessation The importance of vigilant skin care
Managing Raynaud-type symptoms Smoking cessation The importance of vigilant skin care Explanation: Patient teaching for the client with scleroderma focuses on management of Raynaud phenomenon, smoking cessation, and meticulous skin care. Surgical treatment options do not exist and weight loss is not a central concern.
A nurse is caring for a client who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among clients with leukemia?
Monitoring for infection Explanation: In clients with acute leukemia, death typically occurs from infection or bleeding. Compromised nutrition, electrolyte imbalances, and impaired liver function are all plausible, but none is among the most common causes of death in this client population.
An oncology nurse recognizes a client's risk for fluid imbalance while the client is undergoing treatment for leukemia. What related assessments should the nurse include in the client's plan of care? Select all that apply.
Monitoring the client's electrolyte levels Measuring the client's weight on a daily basis Measuring and recording the client's intake and output Auscultating the client's lungs frequently Explanation: Assessments that relate to fluid balance include monitoring the client's electrolytes, auscultating the client's chest for adventitious sounds, weighing the client daily, and closely monitoring intake and output. Liver function is not directly relevant to the client's fluid status in most cases.
A client undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?
Prevention of viral infections from another person's blood Explanation:
he nurse is preparing to care for a client who has scleroderma. The nurse refers to resources that describe CREST syndrome. Which of the following is a component of CREST syndrome? Raynaud phenomenon Thyroid dysfunction Esophageal varices Osteopenia
Raynaud phenomenon
A client's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin, an anticoagulant. When assessing the therapeutic response to this medication, what is the nurse's most appropriate action?
Review the client's international normalized ratio (INR). Explanation: The INR and aPTT serve as useful screening tools for evaluating a client's clotting ability and to monitor the therapeutic effectiveness of anticoagulant medications. The client's platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the client for signs of myelosuppression and capillary refill time does not address the effectiveness of anticoagulants.
client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with what health problem? Rheumatoid arthritis (RA) Systemic lupus erythematosus Osteoporosis Polymyositis
Rheumatoid arthritis (RA) Explanation: In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break down collagen, cause edema and proliferation of the synovial membrane, and ultimately form pannus. Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not involve pannus formation.
A nurse is caring for a client with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this client, the nurse should assign the highest priority to which nursing diagnosis?
Risk for Infection Explanation: Induction therapy places the client at risk for infection, thus this is the priority nursing diagnosis. During the time of induction therapy, the client is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Immobility, confusion, and spiritual distress are possible, but infection is the client's most acute physiologic threat.
A 40-year-old woman was diagnosed with Raynaud phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The client also states that many of her skin surfaces are "stiff, like the skin is being stretched from all directions." The nurse should recognize the need for medical referral for the assessment of what health problem? Giant cell arteritis (GCA) Fibromyalgia (FM) Rheumatoid arthritis (RA) Scleroderma
Scleroderma Explanation: Scleroderma starts insidiously with Raynaud phenomenon and swelling in the hands. Later, the skin and the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the underlying structures. This progression of symptoms is inconsistent with GCA, FM, or RA.
A nurse is caring for a client who is undergoing preliminary testing for a hematologic disorder. What sign or symptom most likely suggests a potential hematologic disorder?
Severe fatigue Explanation: The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC, infections, or anaphylaxis.
The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?
Stop the transfusion immediately. Explanation: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the client's vital signs, and notify the health care provider. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The client's IV access should not be removed.
A client is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the client's health history would most likely predispose her to this deficiency?
The client is a vegan.
nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize? The client will express satisfaction with her ability to perform ADLs. The client will recover from OA within 6 months. The client will adhere to the prescribed plan of care. The client will deny signs or symptoms of OA.
The client will express satisfaction with her ability to perform ADLs. Explanation: Pain management and optimal functional ability are major goals of nursing interventions for OA. Cure is not a possibility and it is unrealistic to expect a complete absence of signs and symptoms. Adherence to the plan of care is highly beneficial, but this is not the priority goal of care; adherence is of little benefit if the regimen has no effect on the client's functional status.
