Prof practice test
The nurse is discussing mammography with a female client at the clinic. The client asks at what age she should begin getting yearly mammograms. What answer should the nurse provide? 45 50 35 40
45 Explanation: The American Cancer Society updated its recommendations in 2015. It recommends yearly mammograms beginning at 45 years of age.
The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a negative biopsy report? The lump and all axillary lymph nodes will be excised. A lump excision is not necessary. A wide excision of lump will be performed. The entire breast and all regional lymph nodes will be excised.
A wide excision of lump will be performed. Explanation: The sentinel node is the first node in which a tumor will drain; if no malignant cells are found there, additional excision or radical removal will not be necessary. Excision of the lump along with a wide margin of cancer-free tissue is standard treatment for malignant tumors.
The nurse is planning care for a client with severe fatigue secondary to anemia. What concept will the nurse use as the basis for planning interventions? Breaking up interventions into smaller, more frequent tasks. Encouraging early and frequent activities. Assisting in prioritizing activities. Determining the balance between rest and activity.
Assisting in prioritizing activities. Explanation: When planning care for a client with severe fatigue secondary to anemia, the nurse should act collaboratively with the client and assist in prioritizing activities. The client ultimately determines the balance between rest and activity, not the nurse. The nurse will balance activities and group nursing interventions in order to prevent client fatigue.
A nurse is caring for a client with Hodgkin lymphoma at the oncology clinic. The nurse should identify what main goal of care? Enhancing quality of life Cure of the disease Palliation Controlling symptoms
Cure of the disease Explanation: The goal in the treatment of Hodgkin lymphoma is cure. Palliation is thus not normally necessary. Quality of life and symptom control are vital, but the overarching goal is the cure of the disease.
Nursing students are reviewing various procedures that can be used to obtain a tissue biopsy of the breast. They demonstrate understanding of the material when they identify which of the following as being done using local anesthesia and intravenous (IV) sedation? Select all that apply. Core needle biopsy Stereotactic biopsy Wire needle localization Excisional biopsy Fine-needle aspiration
Excisional biopsy Wire needle localization Explanation: Surgical biopsies are usually performed using local anesthesia and IV sedation. Types of surgical biopsies include excisional biopsy and wire needle localization. Fine-needle aspiration, core needle biopsy, and stereotactic biopsy are examples of percutaneous biopsies.
A client diagnosed with cancer has the tumor staged and graded based on what? How the tumor tends to grow and the cell type How the tumor spreads and tends to grow How the tumor differentiates the cell type How the tumor spreads and differentiates
How the tumor tends to grow and the cell type Explanation: Tumors are staged and graded based upon how they tend to grow and the cell type before a client is treated for cancer.
A client with ovarian cancer is admitted to the hospital for surgery and the nurse is completing the client's health history. What clinical manifestation would the nurse expect to assess? Fish-like vaginal odor Lower abdominal pelvic pain Fever and chills Increased abdominal girth
Increased abdominal girth Explanation: Clinical manifestations of ovarian cancer include enlargement of the abdomen from an accumulation of fluid. Flatulence and feeling full after a light meal are significant symptoms. In bacterial vaginosis, a fish-like odor, which is noticeable after sexual intercourse or during menstruation, occurs as a result of a rise in the vaginal pH. Fever, chills, and abdominal pelvic pain are atypical.
A nurse assesses a client diagnosed with megaloblastic anemia. Which clinical findings will the nurse most likely find? Select all that apply. Restless leg syndrome Ulcerated corners of the mouth Concave nails Smooth, red tongue Jaundice
Jaundice Ulcerated corners of the mouth Concave nails Explanation: Megaloblastic anemia may cause angular cheilosis (ulcerated corners of the mouth), jaundice (a yellowing of the skin and sclera), and concave nails. A smooth, red tongue and restless leg syndrome are associated with iron deficiency anemia.
A nurse cares for a client with aplastic anemia. Which laboratory results will the nurse expect to find with this client? Select all that apply. White blood cell count 10,000/microliter Neutrophil count 12,000/microliter Hemoglobin 7 g/dL Platelets 35,000 microliters Neutrophil count 17,000/microliter
Neutrophil count 12,000/microliter Hemoglobin 7 g/dL Platelets 35,000 microliters Explanation: Aplastic anemia causes pancytopenia, or overall decrease to all myeloid stem cell-derived cells. Pancytopenia manifests as neutrophil count less than 15,000/ microliter, hemoglobin less than 10 g/dL, and platelets less than 50,000/microliter.
A public health nurse is participating in a campaign aimed at preventing cervical cancer. What strategies should the nurse include is this campaign? Select all that apply. Using safer sex practices Smoking cessation Vitamin D and calcium supplementation Promotion of HPV immunization Encouraging young women to delay first intercourse
Promotion of HPV immunization Encouraging young women to delay first intercourse Smoking cessation Using safer sex practices Explanation: Preventive measures relevant to cervical cancer include regular pelvic examinations and Pap tests for all women, especially older women past childbearing age. Preventive counseling should encourage delaying first intercourse, avoiding HPV infection, participating in safer sex only, smoking cessation, and receiving HPV immunization. Calcium and vitamin D supplementation are not relevant.
Which of the following are true statements about effective radiation therapy? Select all that apply. Cells are least vulnerable during DNA synthesis. Slower-growing tissues at rest (muscle) are more radioresistant. Tumors that are well oxygenated are more sensitive to radiation. Tumors that are small in size and dividing rapidly are more sensitive.
Slower-growing tissues at rest (muscle) are more radioresistant. Tumors that are well oxygenated are more sensitive to radiation. Tumors that are small in size and dividing rapidly are more sensitive. Explanation: All of the statements are true except for A. Cells are most vulnerable during DNA synthesis and mitosis. Tissues that experience frequent cellular division are most sensitive to radiation.
Which options are available to women who have an increased risk of developing breast cancer? Select all that apply. bilateral prophylactic mastectomy annual mammogram and MRI chemoprevention with tamoxifen preventive radiation
annual mammogram and MRI bilateral prophylactic mastectomy chemoprevention with tamoxifen Explanation: Those who choose long-term follow-up receive an annual mammogram and MRI with a clinical breast examination, and perform monthly BSE. Prophylactic bilateral mastectomy is the most invasive of the options; when considering this option, clients are informed that removing the breasts reduces the risk of breast cancer but does not eliminate it completely. Chemoprevention and tamoxifen are options available to women with increased risk of developing breast cancer. Taking the drug tamoxifen may reduce the risk of breast cancer in women who are at high risk by 49%. Radiation is not used to reduce the risk of developing breast cancer.
A client has cancer of the neck and is receiving external beam radiation therapy to the site. The client is experiencing trauma to the irradiated skin. The nurse does all of the following. (Select all that apply.) uses cool water to wash the neck area avoids shaving the irradiated skin inspects for skin damage of the chest area assesses the client for any sun exposure applies an over-the-counter ointment to the skin
assesses the client for any sun exposure avoids shaving the irradiated skin Explanation: The client receiving external beam radiation therapy may experience trauma to the irradiated skin. To prevent further skin damage, the client is to avoid sun exposure and shaving the irradiated skin area. Other skin areas are not damaged, only the irradiated skin. Lukewarm water is to be used to bathe the area. Water of extreme temperature should be avoided. Many over-the-counter ointments contain metals and may cause additional skin damage.
The nurse recognizes that the most common cause of iron deficiency anemia in an adult is chronic alcoholism. lack of dietary iron. bleeding. iron malabsorption.
bleeding. Explanation: Iron deficiency in adults generally indicates blood loss (e.g., from bleeding in the gastrointestinal (GI) tract or heavy menstrual flow). Lack of dietary iron is rarely the sole cause of iron deficiency anemia in adults. The source of iron deficiency should be investigated promptly because iron deficiency in an adult may be a sign of bleeding in the GI tract or colon cancer.
A nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination: on the same day each month. on the first day of the menstrual cycle. immediately after her menses. at the end of her menstrual cycle.
immediately after her menses. Explanation: Premenopausal women should do their self-examination immediately after the menstrual period, when the breasts are least tender and least lumpy. On the first and last days of the cycle, the woman's breasts are still very tender. Postmenopausal women, because their bodies lack fluctuation of hormone levels, should select one particular day of the month to do breast self-examination.
A nurse is caring for a client newly diagnosed with cancer. Which therapies are used to treat cancer? Select all that apply. surgery hyperthermia radiation therapy chemotherapy electroconvulsive therapy
surgery hyperthermia radiation therapy chemotherapy Explanation: Cancer is frequently treated with a combination of therapies using standardized protocols. The basic methods used to treat cancer are surgery, radiation therapy, hyperthermia, and chemotherapy. Electroconvulsive therapy is a method of treatment for mental distress or illness.
A nurse cares for a client who has had a bone marrow aspiration. In addition to the client's aspiration site, what locations on the body does the nurse recognize as having bone marrow? Select all that apply. Pelvis Ribs Sternum Tibia Vertebrae
Pelvis Ribs Vertebrae Sternum Explanation: Bone marrow can be found in the pelvis, ribs, vertebrae, and sternum. Additionally, bone marrow is found on the spongy end of the femur and humerus long bones. The tibia does not have bone marrow.
When a client receives vincristine, an antineoplastic agent that inhibits DNA and protein synthesis, the client needs to be informed to report which symptoms that would be expected side effects of motor neuropathy? Select all that apply. alopecia loss of balance and coordination muscle weakness burning and tingling sensations in the extremities cramps and spasms in the legs
muscle weakness cramps and spasms in the legs loss of balance and coordination Explanation: Muscle weakness, cramps and leg spasms, and loss of balance and coordination are expected side effects of motor nerve damage. Burning and tingling sensations are signs of sensory nerve damage. Alopecia is hair loss, not a motor nerve damage sign.
Which of the following are complications related to polycythemia vera (PV)? Select all that apply. CVA MI Hematuria Splenomegaly Ulcers
CVA MI Ulcers Hematuria Explanation: Patients with PV are at increased risk for thromboses resulting in a CVA or myocardial infarction. Bleeding can be significant and can occur in the form of nosebleeds, ulcers, frank gastrointestinal bleeding, and intracranial hemorrhage. Splenomegaly is a clinical manifestation of PV, not a complication.
Which nursing intervention(s) are related to a client with breast cancer? Select all that apply. Management of complications Client education and preparation for treatment Promotion of positive body image Relieving fear Prevention of social isolation
Client education and preparation for treatment Promotion of positive body image Relieving fear Management of complications Explanation: Client education and preparation for treatment, promotion of positive body image, relieving fear, and management of complications are appropriate nursing interventions. Social isolation is not common in those with breast cancer.
An older client underwent a lumpectomy for a breast lesion that was determined to be malignant. Which factors increase the risk for breast cancer? Select all that apply. Daily alcohol intake Nulliparity Silicone breast implants Obesity Increased age
Daily alcohol intake Increased age Nulliparity Obesity Explanation: Being female, being older than 50 years of age, and having a family history of breast cancer are the most common risk factors. Additional factors include obesity and having no children or having children after 30 years of age. Consuming 2 to 5 alcoholic drinks per day increases breast cancer risk. There is no evidence to support increased breast cancer risk with silicone breast implants.
A 30-year-old client has come to the clinic for her yearly examination. The client asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer? "Most cases of ovarian cancer are attributed to tobacco use." "Use of oral contraceptives increases the risk of ovarian cancer." "Most cases of ovarian cancer are considered to be random, with no obvious causation." "The majority of women who get ovarian cancer have a family history of the disease."
"Most cases of ovarian cancer are considered to be random, with no obvious causation." Explanation: Most cases of ovarian cancer are random, with only 5% to 10% of ovarian cancers having a familial connection. Contraceptives and tobacco have not been identified as major risk factors.
The nurse is completing a physical assessment on a client's lymphatic system. The nurse should palpate for enlarged nodes in which areas? Select all that apply. Submental Inguinal Neck Spinal Popliteal
Popliteal Inguinal Submental Neck Explanation: Palpable lymph node areas include: popliteal, inguinal, submental, and neck. The spinal region does not contain palpable lymph nodes.
Which of the following does a nurse have to assess during the bone marrow transplant (BMT) procedure? Electrolyte levels Psychological status Blood pressure status Urine gravity status
Psychological status Explanation: During the BMT procedure, the nurse assesses the patient's psychological status. Patients experience many mood swings and need emotional support and help throughout this process. Assessing the patient's blood pressure, urine gravity, and electrolyte levels is important for patients undergoing chemotherapy.
A client had a left radical mastectomy and the nurse is providing information on complications that may arise due to removing the axillary lymph nodes. What information should the nurse include in the teaching? Select all that apply. Infection Tissue necrosis Reduced range of motion Skin changes Lymphedema
Reduced range of motion Tissue necrosis Infection Lymphedema Skin changes Explanation: Impaired lymphatic circulation predisposes the client to disfigurement, reduced range of motion, swelling of the limb, skin changes, infection, and in severe cases, tissue necrosis that may require amputation of the limb.
A client has just been diagnosed with breast cancer and the nurse is performing a client interview. In assessing this client's ability to cope with this diagnosis, what would be an appropriate question for the nurse to ask? "Are you feeling alright these days? "Are you concerned about receiving this diagnosis?" "What is your level of education?" "Is there someone you trust to help you make treatment choices?"
"Is there someone you trust to help you make treatment choices?" Explanation: A trusted ally to assist in making treatment choices is beneficial to the client's coping ability. It is condescending and inappropriate to ask if the client is "feeling alright these days" or is concerned about the diagnosis. The client's education level is irrelevant.
A nurse assesses a client who has been diagnosed with DIC. Which indicators are consistent with this diagnosis? Select all that apply. Increased blood urea nitrogen (BUN) and creatinine Polyuria Capillary fill time <3 seconds Cyanosis in the extremities Dyspnea and hypoxia Increased breath sounds
Cyanosis in the extremities Dyspnea and hypoxia Increased blood urea nitrogen (BUN) and creatinine Explanation: Urine output would be decreased in DIC, and capillary fill time would be more than 3 seconds; breath sounds would be decreased.
The nurse cares for a client with iron deficiency anemia. What findings will the nurse expect to find when reviewing the client's CBC results? Select all that apply. Decreased reticulocytes Fragmented RBCs Decreased MCV Increased reticulocytes Increased MCV
Decreased MCV Decreased reticulocytes Explanation: In iron deficiency anemia (hypoproliferative anemia), the nurse can expect to find decreased MCV (mean corpuscular volume), and decreased reticulocytes. Fragmented RBCs are found in hemolytic anemias.
A male client has a hemoglobin count of 10.2 gm/dl, a hematocrit value of 36%, and a low ferritin level. What question should the nurse ask first? Have you experienced abdominal pain? Can you explain your typical diet? How much alcohol do you drink? Are you taking iron supplements?
Have you experienced abdominal pain? Explanation: The laboratory data support that the client has iron-deficiency anemia. The most common cause of iron-deficiency anemia in men is bleeding from ulcers, gastritis, inflammatory bowel disease, or gastrointestinal tumors. People who experience these problems may report abdominal pain. The nurse will make further assessments and may ask the other questions.
When malignant cells are killed (tumor lysis syndrome), intracellular contents are released into the bloodstream. This leads to which of the following? Select all that apply. Hyperuricemia Hypercalcemia Hyperphosphatemia Hyperkalemia
Hyperkalemia Hyperuricemia Hyperphosphatemia Explanation: When intracellular contents are released into the bloodstream, phosphorous is elevated. This results in an inverse decline in the levels of calcium, so hypercalcemia would not occur
During a recent visit to the clinic, a woman presents with erythema of the nipple and areola on the right breast. She states this started several weeks ago and she was fearful of what would be found. The nurse should promptly refer the client to her primary provider because the client's signs and symptoms are suggestive of what health problem? Paget disease Peau d'orange Nipple inversion Acute mastitis
Paget disease Explanation: Paget disease presents with erythema of the nipple and areola. Peau d'orange, which is associated with breast cancer, is caused by interference with lymphatic drainage, but does not cause these specific signs. Nipple inversion is considered normal if long-standing; if it is associated with fibrosis and is a recent development, malignancy is suspected. Acute mastitis is associated with lactation, but it may occur at any age.
A nurse is obtaining health histories from clients at a busy low-income clinic. Which clients should the nurse follow more closely as being at the highest risk for developing breast cancer? Select all that apply. The client who is over 50 years of age The male client with a family history of prostate cancer The client with a mother who had breast cancer The client who is African American The client who has relatives with the BRCA1 mutated gene
The client who has relatives with the BRCA1 mutated gene The client with a mother who had breast cancer Explanation: There are several risk factors that the nurse must identify; however, the most important risk factor to be identified is the presence of the mutated BRCA1 gene, which makes the client "very likely" to develop breast cancer. Breast cancer family history is another significant risk factor. Other risk factors include being female and being older than 50 years, but these clients are not at as high a risk for the development of breast cancer. Males are not a high-risk group. White women are at a higher risk than African Americans.
A client with multiple myeloma reports uncomfortable muscle cramping. Which nursing interventions will the nurse implement in response to the client's report of symptoms? Select all that apply. Warn client to avoid abrupt position change Encourage hydration Encourage range of motion exercises Encourage ambulation Warn client to avoid extremes in temperatures
Encourage hydration Encourage ambulation Explanation: Muscle cramping can be alleviated or reduced by encouraging hydration and ambulation. Warning the client to avoid abrupt position change best supports the client with postural hypotension. Paresthesias (tingling) can best be mediated with range of motion exercises. Clients experiencing hypoesthesia should be warned to avoid extremes in temperatures.
The nurse is assessing a patient who is a strict vegetarian. What type of anemia is the nurse aware that this patient is at risk for? Megaloblastic anemia Sickle cell anemia Iron deficiency anemia Aplastic anemia
Megaloblastic anemia Explanation: Strict vegetarians are at risk for megaloblastic anemias, which are characterized by the presence of abnormally large, nucleated RBCs, if they do not supplement their diet with vitamin B12.
The nurse cares for several clients with hematological conditions. Which assessment needs will the nurse prioritize for the client with aplastic anemia? Select all that apply. Bleeding Injury Oxygenation Perfusion Infection
Infection Bleeding Explanation: All clients with aplastic anemia need to have prioritized assessments for infection and bleeding. Injury, oxygenation, and perfusion are not the priority assessments for clients with aplastic anemia.
A nurse is examining a client's breasts. Which of the following would alert the nurse to a possible problem? Select all that apply. Spontaneous nipple discharge Right breast slightly larger than left Nipple retraction with position changes Pitting of the breast skin Prominent venous pattern
Prominent venous pattern Pitting of the breast skin Nipple retraction with position changes Spontaneous nipple discharge Explanation: Abnormal findings during a breast assessment include a prominent venous pattern, which may signal the increased blood supply required by a tumor; pitting of the breast skin, which may indicate blocked lymphatic drainage resulting from a tumor; nipple retraction with position changes, which signals an underlying mass; and spontaneous nipple discharge. A slight variation in breast size is common and generally unremarkable.
A patient is receiving chemotherapy for breast cancer. Her most recent laboratory test results are as follows:Erythrocytes 4,500,000/cu mmHemoglobin 12.0 gm/dLHematocrit 35%Leukocytes 4,600 gm/dLThrombocytes 125,000/cu mmWhich results suggests some evidence of bone marrow suppression? Erythrocyte count Thrombocyte count Leukocyte count Hemoglobin level
Thrombocyte count Explanation: The thrombocyte count is below 150,000/cu mm, indicating thrombocytopenia and bone marrow suppression. The erythrocyte count, hemoglobin, hematocrit, and leukocyte count are within normal limits.
A nurse cares for several clients with anemia and notes that all the clients have different types of anemia. What is the nurse's best understanding of how anemias are classified, based on the deficiency of erythrocytes? Select all that apply. Quantity of erythrocytes Destruction of erythrocytes Loss of erythrocytes Shape of erythrocytes Defective production of erythrocytes
Defective production of erythrocytes Destruction of erythrocytes Loss of erythrocytes Explanation: A physiologic approach classifies anemia according to whether the deficiency in erythrocytes is caused by a defect in their production (i.e., hypoproliferative anemia), by their destruction (i.e., hemolytic anemia), or by their loss (i.e., bleeding). Shape and quantity of erythrocytes are not categories of classifications of anemia.
A nurse prepares teaching for a group of clients with chronic myeloid leukemia (CML). When planning the teaching on medication adherence, which factors associated with lower oral therapy adherence will the nurse keep in mind? Select all that apply. Lower self-report of functional status Taking medication independent of meals Not participating in a clinical trial Low socioeconomic status Living alone
Living alone Low socioeconomic status Not participating in a clinical trial Taking medication independent of meals Explanation: Adherence to the oral medication therapeutic regimen is critical to optimal client outcomes. Various factors lead to lower adherence rates to the oral medication therapeutic regimen. These may include: living alone, low socioeconomic status, not participating in a clinical trial, and taking medication independent of meals. A higher self-report of functional status
The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse? The client is at risk for spontaneous and uncontrolled bleeding. Trauma and microabrasions from a non-electric razor may contribute to anemia. Fragile tissues and altered clotting mechanisms may result in hemorrhage. The client is at risk for infection from microorganisms.
Trauma and microabrasions from a non-electric razor may contribute to anemia. Explanation: In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.
A client is admitted for intracavitary radiation as treatment for her reproductive tract cancer. Which client statement demonstrates to the nurse that the client understands the planned procedure? "While I'm in surgery, the doctors will focus the radiation directly on the area to kill the cells." "I'm going to have a catheter inserted to drain my urine so I don't need to get out of bed to go to the bathroom." "I can sit at the side of my bed but I can't get out of the bed to walk around." "I'll be taken to a special x-ray room where a machine will direct the radiation to my abdomen."
"I'm going to have a catheter inserted to drain my urine so I don't need to get out of bed to go to the bathroom." Explanation: Intracavitary irradiation involves the insertion of specially prepared applicators that are loaded with radioactive material into the endometrial cavity and vagina. The client must be isolated in a private room and remain in bed. A urinary catheter is inserted to allow for urinary elimination. External radiation therapy involves a machine that directs radiation to the specified area. Intraoperative radiation involves radiation applied directly to the affected area during surgery.
A nurse is teaching a client about why ovarian cancer is largely considered to be a lethal cancer of the female reproductive system. What should the nurse include in the teaching? Select all that apply. Ovarian cancer's vague symptoms are often ignored. Tumors are typically far advanced and inoperable by the time of diagnosis. Tumors present with nonspecific symptoms. There is no effective screening test. Tumor-specific antigens are helpful in screening.
Tumors are typically far advanced and inoperable by the time of diagnosis. Ovarian cancer's vague symptoms are often ignored. Tumors present with nonspecific symptoms. There is no effective screening test. Explanation: Although other types of female reproductive system cancers occur with greater incidence, ovarian tumors are the leading cause of death from gynecologic malignancies. Tumors of the ovary have been lethal largely because they present with nonspecific symptoms, which are often ignored. There is no effective screening test; tumors frequently are far advanced and inoperable by the time the tumors are diagnosed. Tumor-specific antigens are used after diagnosis of ovarian cancer.
The registered nurse (RN) and licensed practical nurse (LPN) are preparing an educational program for clients who may be at risk for the development of iron-deficiency anemia. Which clients would receive the greatest benefit from this program? Select all that apply. An older adult client on a fixed income A client who is a vegetarian A client who lives in a nursing home A client with Crohn's disease A young female client with bulimia nervosa
A young female client with bulimia nervosa An older adult client on a fixed income A client with Crohn's disease Explanation: Those who consume a healthy diet absorb less than 10% of the iron in food. Clients whose nutrition is compromised by unhealthy dieting or who cannot afford to eat a healthy diet, lack knowledge about nutrition, or have malabsorption disorders are at great risk for iron-deficiency anemia. A young female client with bulimia nervosa has an unhealthy diet. An older adult client on a fixed income may not have the funds to eat a healthy diet. A client with Crohn's disease has a malabsorption syndrome. A client who resides in a nursing home has prepared meals as well as available supplements if required. A client who is a vegetarian is still able to receive ample iron supplementation in the vegetables being eaten.
An older adult client at the free clinic has a history of seizures and presents with severe fatigue, frequent headaches, and a sore and beefy red tongue. Which of the following does the nurse suspect as causes of the client's current condition? Select all that apply. Poor nutrition Intestinal disorders Alcoholism Not eating vegetables
Alcoholism Intestinal disorders Not eating vegetables Poor nutrition Explanation: The client is showing signs of folic acid deficiency anemia caused by a deficiency of folate or folic acid in the client. Alcoholism, Intestinal disorders that affect absorption, lack of vegetables or other folate-containing foods in the diet where folic acid is not being supplemented or consumed by other sources, and poor nutrition are all causes of folic acid deficiencies.
A client has been diagnosed with multiple myeloma. Which of the following laboratory values should the nurse expect to find in a client with multiple myeloma? Decreased serum protein Polycythemia vera Increased urinary protein Decreased calcium level
Increased urinary protein Explanation: A characteristic finding in multiple myeloma is protein in the urine. Other laboratory findings include increased serum protein, hypercalcemia, anemia, and hyperuricemia. Polycythemia vera is not found in multiple myeloma.
What interventions are most appropriate for the nurse to include in the plan of care for a client at risk for infection? Select all that apply. Auscultate lung sounds every shift and as needed. Place fresh flowers on a shelf on the opposite wall from the client. Assess skin and mucus membranes every shift. Encourage the client to take deep breaths every 4 hours while awake. Provide oral hygiene once daily.
Assess skin and mucus membranes every shift. Auscultate lung sounds every shift and as needed. Encourage the client to take deep breaths every 4 hours while awake. Explanation: Interventions for risk for infection include assessing skin and mucus membranes every shift, auscultating lung sounds every shift and as needed, and encouraging deep breaths every 4 hours while the client is awake. No fresh flowers are allowed in the room because of germs found in stagnant water. Oral hygiene should be provided after meals and every 4 hours while the client is awake.
A nurse is reviewing the various manifestations of anemia across the lifespan and notes a significant difference in how the older adult client responds to anemia versus a younger individual. Which concepts related to aging and the response to anemia does the nurse recognize? Select all that apply. Confusion is often greater than in younger clients. Fatigue is often greater than in younger clients. Dyspnea is not reported as often as in younger clients. Cardiac output increases more than in younger clients. Heart rate does not increase as much as in younger clients.
Fatigue is often greater than in younger clients. Heart rate does not increase as much as in younger clients. Confusion is often greater than in younger clients. Explanation: In the older adult client, fatigue, dyspnea, and confusion associated with anemia may be seen more readily versus a younger client. Cardiac output and heart rate compensatory mechanisms do not increase as much with older adult clients versus younger clients with anemia. Fatigue, dyspnea, and confusion related to anemia is often greater in the older adult client versus the younger client.
The nurse is assessing the diet of a female client. To decrease the risk of cancer in general, the nurse instructs the client to Ingest two to three servings of fruits and vegetables each day. Decrease cigarette smoking from one pack/day to 1/2 pack/day. Limit alcohol ingestion to one drink per day. Include at least 6 ounces of meat in meals every 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.
The nurse is administering 2 units of packed RBCs to an older adult patient who has a bleeding duodenal ulcer. The patient begins to experience difficulty breathing and the nurse assesses crackles in the lung bases, jugular vein distention, and an increase in blood pressure. What action by the nurse is necessary if the reaction is severe? (Select all that apply.) Discontinue the transfusion. Place the patient in an upright position with the feet dependent. Administer diuretics as prescribed. Continue the infusion but slow the rate down. Administer oxygen.
Place the patient in an upright position with the feet dependent. Administer diuretics as prescribed. Discontinue the transfusion. Administer oxygen. Explanation: Signs of circulatory overload include dyspnea, orthopnea, tachycardia, and sudden anxiety. Jugular vein distention, crackles at the base of the lungs, and an increase in blood pressure can also occur. If the transfusion is continued, pulmonary edema can develop, as manifested by severe dyspnea and coughing of pink, frothy sputum. If fluid overload is mild, the transfusion can often be continued after slowing the rate of infusion and administering diuretics. However, if the overload is severe, the patient is placed upright with the feet in a dependent position, the transfusion is discontinued, and the primary provider is notified. Oxygen and morphine may be needed to treat severe dyspnea (see Chapter 29).
A client who is 4 months postpartum reports significant left breast pain, edema, redness, and an elevated temperature. What would the physician likely order? Select all that apply. increased activity antibiotic therapy a supportive bra biopsy a breast shield.
antibiotic therapy a supportive bra Explanation: Treatment for mastitis consists of antibiotics and local application of cold compresses to relieve discomfort. The client should wear a snug bra. Adequate rest and hydration are important. Activity is neither encouraged nor restricted. The client should avoid wearing breast shields, which trap breast milk and moisture around the nipple. A biopsy would not be indicated for mastitis.
The nurse is providing an educational presentation on dietary recommendations for reducing the risk of cancer. Which of the following food selections would demonstrate a good understanding of the information provided in the presentation? Select all that apply. Steamed broccoli and carrots Vegetable and cheddar quiche Turkey breast on whole wheat bread Egg white omelet with spinach and mushrooms Smoked salmon Crispy chicken Caesar Salad
Egg white omelet with spinach and mushrooms Steamed broccoli and carrots Turkey breast on whole wheat bread Explanation: Foods high in fat and those that are smoked or preserved with salt or nitrates are associated with increased cancer risks. An omelet made of egg whites and vegetables is a healthy low fat selection as are steamed broccoli/carrots and turkey breast on whole grain bread. A salad can be a healthy selection but Caesar salads contain much fat from the dressing and addition of cheeses and fried chicken. Salmon that is not smoked would be a good selection. Quiche usually contains high-fat milk, crème, eggs, and cheese.
A client was admitted to the hospital with the following laboratory values: hemoglobin 5 g/dL, leukocyte count 2000/mm3, and a platelet count of 48,000/mm3; abnormally shaped erythrocytes and hypersegmented neutrophils were seen. The platelets appear abnormally large. A bone marrow biopsy was competed and revealed hyperplasia. Based on this information, the nurse determines that client most likely has which diagnosis? Thalassemia Folic acid deficiency Hemolytic anemia Sickle cell anemia
Folic acid deficiency Explanation: Anemia caused by a deficiency of folic acid cause bone marrow and peripheral blood changes. The erythrocytes that are produced are abnormally large and are called megaloblastic red cells. Other cells derived from the myeloid stem cell are also abnormal. A bone marrow analysis reveals hyperplasia (abnormal increase in the number of cells). Pancytopenia (a decrease in all myeloid stem cell-derived cells) can develop. In advanced stages of disease, the hemoglobin value may be as low as 4-5 g/dL, the leukocyte count 2,000-3,000/mm3, and the platelet count less than 50,000/mm3. Cells that are released into the circulation are often abnormally shaped. The neutrophils are hypersegmented. The platelets may be abnormally large. The erythrocytes are abnormally shaped.
A client with ovarian cancer is ordered hydroxyurea, an antimetabolite drug. Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. What mechanism of action do antimetabolites interferes with? cell division or mitosis during the M phase of the cell cycle the chemical structure of deoxyribonucleic acid (DNA) and chemical binding between DNA molecules (cell cycle-nonspecific) one or more stages of ribonucleic acid (RNA) synthesis, DNA synthesis, or both (cell cycle-nonspecific) normal cellular processes during the S phase of the cell cycle
normal cellular processes during the S phase of the cell cycle Explanation: Antimetabolites act during the S phase of the cell cycle, contributing to cell destruction or preventing cell replication. They're most effective against rapidly proliferating cancers. Miotic inhibitors interfere with cell division or mitosis during the M phase of the cell cycle. Alkylating agents affect all rapidly proliferating cells by interfering with DNA; they may kill dividing cells in all phases of the cell cycle and may also kill nondividing cells. Antineoplastic antibiotic agents interfere with one or more stages of the synthesis of RNA, DNA, or both, preventing normal cell growth and reproduction.
Which of the following is an expected outcome for a client 24 hours after an abdominal hysterectomy? Bowel sounds will be heard on auscultation. The perineal pad will have a minimal amount of serous drainage. The client will express feelings of a positive body image. The client will perform leg exercises hourly.
The client will perform leg exercises hourly. Explanation: During the first 24 hours after an abdominal hysterectomy, the client is at risk for development of thrombophlebitis because of potential interference with pelvic and leg circulation. Leg exercises are essential to promote circulation and prevent a thrombus. Bowel sounds may not be heard immediately after surgery. It may take up to 48 hours for peristalsis to return. Perineal pads are used after a vaginal hysterectomy, not an abdominal hysterectomy. In the early phases of recovery, the client will be more likely to focus on expressing feelings of discomfort rather than a positive body image.