Care III Exam 5 Practice Questions
a. Bowel function
A 4-year-old child is receiving postoperative care for surgical resection of a Wilms tumor. In addition to urinary functioning, the nurse should make which priority postoperative assessment? a. Bowel function b. Neurologic status c. Presence of bone pain d. Activity level
b. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring
A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock? a. The patient has an increased systemic vascular resistance. This increases preload and decreases afterload, which will cause severe hypotension b. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring c. The patient's parasympathetic nervous system is being unopposed by the sympathetic nervous system, which leads to severe hypotension d. The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has led to severe hypotension
b. Decreased socialization
A 67-yr-old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis, she was very active in her neighborhood association. Her husband is concerned because his wife is staying at home and missing her usual community activities. Which common EOL psychologic manifestation is she most likely demonstrating? a. Peacefulness b. Decreased socialization c. Decreased decision making d. Anxiety about unfinished business
a. Paraplegia with a flaccid paralysis
A 70 year old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock? a. Paraplegia with a flaccid paralysis b. Tetraplegia with total sensory loss c. Total hemiplegia with sensory and motor loss d. Spastic tetraplegia with loss of pressure sensation
a. Hypercalcemia
A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is confused when awake, and complains of nausea and constipation. Which complication of cancer is this most likely caused by? a. Hypercalcemia b. Tumor lysis syndrome c. Spinal cord compression d. Superior vena cava syndrome"
a. Hospice care
A 90-year-old client expresses a wish to die at home after being told that an esophageal stricture prevents swallowing. The client refuses a feeding tube. The family fully supports this decision. What would be the most appropriate resource for the nurse to call? a. Hospice care b. Palliative care c. An attorney d. The medical examiner's office
a. Bleeding and infection
A cancer patient who has underwent a bone marrow transplant is at most risk for what? a. Bleeding and infection b. Congestive heart failure c. Liver failure d. HIV
c. Best treated by receiving a long-acting and a short-acting opioid
A cancer patient who reports ongoing, constant moderate pain with short periods of severe pain during dressing changes is... a. Probably exaggerating his pain b. In need of a referral for surgical treatment of his pain c. Best treated by receiving a long-acting and a short-acting opioid d. Best treated by regularly scheduled short-acting opioids plus acetaminophen
d. Proliferation of cancer cells despite host control mechanisms
A characteristic of the stage of progression in cancer development is which of the following? a. Oncogenic viral transformation of target cells b. A reversible steady growth facilitated by carcinogens c. A period of latency before clinical detection of cancer d. Proliferation of cancer cells despite host control mechanisms
d. An abdominal mass
A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect which of the following? a. Gross hematuria b. Dysuria c. Nausea and vomiting d. An abdominal mass
a. Do not put pressure on the abdomen
A child is diagnosed with Wilms' tumor. In planning teaching interventions, what key point should the nurse emphasize to the parents? a. Do not put pressure on the abdomen b. Frequent visits from friends and family will improve morale c. Appropriate protective equipment should be worn for contact sports d. Encourage the child to remain active.
a. Raise the head of the bed, lower the legs, and remove constrictive clothing
A client has suffered a spinal cord injury after a fall. When he is brought in for care, the client experiences diaphoresis and headache. The nurse notes that his blood pressure is 174/102 mmHg. Which action should the nurse perform first? a. Raise the head of the bed, lower the legs, and remove constrictive clothing b. Apply hemodynamic monitoring c. Assess the client for fecal impaction d. Ask the client to perform the Valsalva maneuver
d. Monitor respiratory effort and oxygen saturation level
A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? a. Determine the level at which the client has intact sensation b. Assess the level at which the client has retained mobility c. Check blood pressure and pulse for signs of spinal shock d. Monitor respiratory effort and oxygen saturation level
a. "The head of bed cannot be raised more than about 15 degrees while the implant is in place." **HOB cannot be raised > 15 degrees while implant is in place to reduce the risk of dislodging the device
A client with cervical cancer is going to have internal radiation therapy (brachytherapy). The nurse should provide what explanation about what to expect during this therapy? a. "The head of bed cannot be raised more than about 15 degrees while the implant is in place." b. "You will be able to have frequent visitors such as friends and family." c. "It will be helpful to increase your intake of high-fiber foods during therapy." d. "You can walk only in your room, not in the hallway, during therapy.
b. Insert an intravenous catheter for IV access e. Initiate oxygen therapy
A client with esophageal cancer arrives in the emergency department with shortness of breath, tachycardia, hypotension, and cyanosis. Cardiac tamponade is diagnosed. Which intervention would the nurse expect to include in this client's care? (Select all that apply) a. Administer a vasodilator agent intravenously b. Insert an intravenous catheter for IV access c. Prepare to assist healthcare provider with a thoracentesis d. Prepare the client for radiation therapy e. Initiate oxygen therapy
a. Removing unnecessary clothing b. Changing damp bed linens e. Turning on the circulating fan in the room
A client with hyperthermia reports feeling hot and miserable. Which action should the nurse perform to help this client achieve comfort? (Select all that apply) a. Removing unnecessary clothing b. Changing damp bed linens c. Measuring temperature every 2 hours d. Administering antipyretics as prescribed e. Turning on the circulating fan in the room
b. To reduce the size of the tumor
A client with lung cancer is admitted to the oncology clinic for radiation therapy to treat spinal cord compression. The client's spouse asks why radiation is being done. The nurse's response would include that radiation therapy should have which effect? a. To eradicate the tumor b. To reduce the size of the tumor c. To effectively treat all oncologic emergencies d. Provide an alternative to chemotherapy for the lung tumor
c. Superior vena cava syndrome
A client with squamous cell carcinoma of the lung comes to the emergency department with shortness of breath and respiratory difficulty. The nurse notes cyanosis and edema of the face and arms. Based on these findings, the nurse suspects the client is probably experiencing which oncologic emergency? a. Spinal cord compression b. Syndrome of inappropriate antidiuretic hormone (SIADH) c. Superior vena cava syndrome d. Neurogenic shock
d. "Breast cancer tends to metastasize to the bones"
A client with stage II breast cancer asks the nurse about sites of metastasis for this cancer. Which of the following responses should the nurse provide? a. "It's too soon to worry about something that might not happen" b. "Breast cancer tends to metastasize to the stomach" c. "Metastasis is unlikely since we detected your cancer early" d. "Breast cancer tends to metastasize to the bones"
b. Make arrangements for the partner to receive a meal in the client's room
A dying client's partner is afraid to get a meal in the cafeteria for fear the client will die while she is gone. No other family members or visitors are present. The client is nonresponsive, has an irregular and slow pulse, and has Cheyne-Stokes respirations. What is the best course of action by the nurse? a. Encourage the partner to eat in the cafeteria since the client is nonresponsive and won't know the partner is gone b. Make arrangements for the partner to receive a meal in the client's room c. Promise to call the partner if any changes occur and ask an unlicensed assistive person to sit with the client while the partner is away d. Refrain from saying anything that interferes with the partner's decision
b. The patient's visitors bring in some fresh peaches from home
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates several times a day in the room b. The patient's visitors bring in some fresh peaches from home c. The patient cleans with a warm washcloth after having a stool d. The patient uses soap and shampoo to shower every other day
c. A private room with neutropenic precautions **Because of the immunosuppression, the client is at severe risk of infection --> measures such as a private room and neutropenic precautions must be instituted to protect the client from sources of infection
A new nurse on the unit is admitting a severely immunosuppressed client who is receiving radiation therapy. The preceptor determines that the new nurse understands necessary precautionary measures when the new nurse admits the client to which room? a. A semiprivate room with a client who has pneumonia b. A private room with contact isolation c. A private room with neutropenic precautions d. A private room with no isolation precautions
d. Immobilize the client's cervical spine
A nurse in the ED has assessed a client's airway, breathing, and circulation following a head injury from a fall at work. Which of the following actions is the priority to perform next? a. Question the client's coworkers about the mechanism of injury b. Check the client's pupils for equality and reaction to light c. Measure the client's alertness using the Glasgow Coma Scale d. Immobilize the client's cervical spine
d. A fresh fruit basket **raw fruits and vegetables have a high risk of bacteria
A nurse is admitting a client who has multiple myeloma and a WBC count of 2,200. Which of the following foods should the nurse prohibit the family members from bringing to the client? a. Fried chicken from a fast food restaurant b. A case of canned nutritional supplements c. A factory-sealed box of chocolates d. A fresh fruit basket
d. Report of a headache
A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? a. Flushing of lower extremities b. Hypotension c. Tachycardia d. Report of a headache
d. Hypothalamus
A nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which of the following areas of the client's brain is affected? a. Wernicke's area b. Cerebral cortex c. Basal ganglia d. Hypothalamus
d. Facial edema
A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome? a. Irregular cardiac rhythm b. Numbness in the hands c. Muscle cramps d. Facial edema
b. Place the client in high-Fowler's **to decrease BP
A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vitals, which of the following actions should the nurse perform next? a. Administer nifedipine b. Place the client in high-Fowler's c. Check for urinary retention d. Check for fecal impaction
c. Keep the door to the client's room closed
A nurse is caring for a client who is receiving brachytherapy. Which of the following measures should the nurse include in the client's plan of care? a. Plan to spend extra time with the client to provide emotional support b. Ensure the chemotherapy medications do not extravasate into the client's tissues c. Keep the door to the client's room closed d. Encourage family members and friends to visit for at least 1 hour
c. Pancytopenia **deficiency of WBCs, RBCs, and platelets
A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse effects should the nurse anticipate from the chemotherapy? a. Gingival hyperplasia b. Hirsutism c. Pancytopenia d. Weight gain
d. Offer mints
A nurse is caring for a client who is receiving radiation therapy for breast cancer and reports a metallic taste in the mouth. Which of the following dietary recommendations should the nurse share with the client? a. Eat with metal utensils b. Limit coffee c. Avoid citrus foods d. Offer mints
d. Use gravies or sauces to soften food
A nurse is caring for a client who is receiving radiation therapy for mouth cancer and reports a dry mouth. Which of the following dietary recommendations should the nurse provide? a. Offer graham crackers as a snack b. Avoid foods containing citrus c. Rinse the mouth with an alcohol-based mouthwash before eating d. Use gravies or sauces to soften food
a. Prohibit visitors from bringing fresh flowers and plants into the client's room c. Ensure thorough cleaning of the client's' room and bathroom daily e. Use dedicated equipment such as stethoscopes
A nurse is caring for a client who recently had chemotherapy and now has myelosuppression. Which of the following interventions should the nurse initiate? (Select all that apply) a. Prohibit visitors from bringing fresh flowers and plants into the client's room b. Encourage frequent visits from family c. Ensure thorough cleaning of the client's' room and bathroom daily d. Replace wound dressings every other day e. Use dedicated equipment such as stethoscopes
d. Radioactive infusions or insertions into or near the tumor
A nurse is caring for a client who will receive brachytherapy to treat uterine cancer. The nurse should ensure the client understands that she will receive which of the following interventions? a. Chemotherapy via a central venous access device b. Radiation to the tumor from an external source c. Precise delivery of high dose radiation after tumor imaging d. Radioactive infusions or insertions into or near the tumor
a. "I have cancer of the colon that has begun to spread"
A nurse is caring for a client whose surgeon informed him postop that he has a metastasizing malignant neoplasm in the colon. Which of the following statements by the client should the nurse identify as an indication that the clients understands this information? a. "I have cancer of the colon that has begun to spread" b. "I have growths in my bowel that the doctor can easily treat" c. "As long as my tumor doesn't get any bigger, I'll be okay" d. "There is not much point in having more treatments"
d. Overexposure to sunlight
A nurse is collecting a client's health history. Which of the following findings is the highest risk factor for the client developing skin cancer? a. Age over 60 b. Genetic predisposition c. Light-skinned race d. Overexposure to sunlight
c. Stop the infusion
A nurse is monitoring a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site, and the nurse notes fluid leaking around the catheter. Which of the following actions should the nurse take first? a. Take a photograph of the peripheral IV site b. Obtain and record the client's vital signs c. Stop the infusion d. Identify all medications administered through the IV site for the past 24 hrs
b. Abdominal cramps
A nurse is performing an admission assessment for a client who has colorectal cancer. Which of the following manifestations should the nurse expect? a. Hematuria b. Abdominal cramps c. Weight gain d. Polycythemia
b. Remind the client to use an electric razor
A nurse is planning care for a client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia? a. Monitor visitors for manifestations of infection b. Remind the client to use an electric razor c. Encourage frequent rest periods d. Instruct the client to rinse their mouth daily with normal saline
b. "I will use lemon and glycerin swabs after meals" **these cause further mouth drying
A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching? a. "I will use a soft toothbrush or foam swab for oral care" b. "I will use lemon and glycerin swabs after meals" c. "I will remove my dentures except while eating" d. "I will rinse my mouth frequently with hydrogen peroxide solution"
c. "Use an electric razor while shaving" **to prevent cuts bc there is an increased risk of bleeding w/ thrombocytopenia
A nurse is teaching a client who has leukemia and has developed thrombocytopenia. Which of the following instructions should the nurse include in the teaching? a. "Limit flossing your teeth to once a week" b. "Gently blow your nose if needed" c. "Use an electric razor while shaving" d. "Wear shoes that have a soft sole"
a. Maintaining the patient's hope
A patient has recently been diagnosed with early stages of breast cancer. What is most appropriate for the nurse to focus on? a. Maintaining the patient's hope b. Preparing a will and advance directives c. Discussing replacement child care for the patient's children d. Discussing the patient's past experiences with her grandmother's cancer
c. Teach the family members to provide oral care and mouth swabs for the patient
A patient is at home receiving end of life care on hospice and the family wants to know what can be done for the patient's dehydration. The most appropriate action by the nurse would be what? a. Start an IV and provide IV fluids b. Instruct the family to constantly encourage patient to drink large amounts of water c. Teach the family members to provide oral care and mouth swabs for the patient d. Teach the family to record strict I&Os
c. Temperature of 101.9° F, fatigue, and shortness of breath
A patient on chemotherapy and radiation for head and neck cancer has a WBC count of 1.9 × 103/μL, hemoglobin of 10.8 g/dL, and a platelet count of 99 × 103/μL. Based on the CBC results, what is the most serious clinical finding? a. Cough, rhinitis, and sore throat b. Fatigue, nausea, and skin redness at site of radiation c. Temperature of 101.9° F, fatigue, and shortness of breath d. Skin redness at site of radiation, headache, and constipation
d. Rinse the mouth before and after each meal and at bedtime with a saline solution **The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended.
A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash d. Rinse the mouth before and after each meal and at bedtime with a saline solution
c. Measure the patient's blood pressure
A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. Call the health care provider b. Check the patient's temperature c. Measure the patient's blood pressure d. Elevate the head of the bed to 90 degrees
c. "Malignant tumors may spread to other tissues or organs."
A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."
b. Hypotension
A patient with a T4 spinal cord injury experiences neurogenic shock as a result of SNS dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased urine output d. Peripheral vasoconstriction
b. Hypotension
A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction
b. Assess for a full bladder
A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? a. Try to calm the patient and make the environment soothing b. Assess for a full bladder c. Notify the healthcare provider d. Prepare the patient for diagnostic radiography.
c. Administer prescribed antiemetics 1 hour before the treatments
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate? a. Have the patient eat large meals when nausea is not present b. Offer dry crackers and carbonated fluids during chemotherapy c. Administer prescribed antiemetics 1 hour before the treatments d. Give the patient two ounces of a citrus fruit beverage during treatments
c. Atropine **Atropine will quickly increase the heart rate and block the effects of the parasympathetic system on the body
A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT? a. Adenosine b. Warfarin c. Atropine d. Norepinephrine
c. Administer pain medications on a scheduled basis
A patient with stage 4 pancreatic cancer is on hospice care. The patient has been having pain secondary to metastasis to his bones. To best control his pain, the nurse should follow which regimen? a. Only administer prn pain medications for this client b. Do not delivery any opioid pain medications because of risk for respiratory depression c. Administer pain medications on a scheduled basis d. Focus on nonpharmacological approaches to relieve pain so the patient will not be drowsy
c. Possible bladder irritant
After taking all the necessary steps for a patient who has developed autonomic dysreflexia, what should the nurse assess FIRST as a possible cause of this condition? a. Skin break down b. Blood glucose c. Possible bladder irritant d. Last bowel movement
a. Improve her quality of life d. Focus on reducing the severity of disease symptoms
An 80-yr-old female patient is receiving palliative care for heart failure. The primary purpose(s) of her receiving palliative care is (are) to do what? (Select all that apply) a. Improve her quality of life b. Assess her coping ability with disease c. Have time to teach patient and family about disease d. Focus on reducing the severity of disease symptoms e. Provide care that the family is unwilling or unable to give
b. Ibuprofen (Advil) d. Acetaminophen (Tylenol)
Appropriate nonopioid analgesics for mild pain include which of the following? (Select all that apply) a. Oxycodone b. Ibuprofen (Advil) c. Lorazepam (Ativan) d. Acetaminophen (Tylenol)
c. Obtain more information from the patient about the family history
During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Teach the patient about the need for a colonoscopy at age 50 b. Teach the patient how to do home testing for fecal occult blood c. Obtain more information from the patient about the family history d. Schedule a sigmoidoscopy to provide baseline data about the patient
b. Maintaining a fluid intake of 3 to 4 L/day
During care of the patient with multiple myeloma, an important nursing intervention is which of the following? a. Limiting weight-bearing and ambulation b. Maintaining a fluid intake of 3 to 4 L/day c. Assessing lymph nodes for enlargement d. Administration of calcium supplements
a. L1-2
During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8
b. Provide warm oral fluids c. Cover with a warmed blanket e. Cover the head with a cap.
From an assessment of vital signs, the nurse learns that a client has a body temperature of 35.7°C (96.2°F). Which action should the nurse take? (Select all that apply.) a. Provide oral hygiene b. Provide warm oral fluids c. Cover with a warmed blanket d. Administer a tepid sponge bath e. Cover the head with a cap.
c. Is an appropriate nursing action
Giving opioids to an actively dying patient who has moderate to severe pain... a. May cause addiction b. Will likely be ineffective c. Is an appropriate nursing action d. Will likely hasten the person's death
d. Metozol (metoclopramide)
Nausea and vomiting is an expected side effect of chemotherapeutic drug use. Which of the following drugs should be administered to a client on chemotherapy to prevent nausea and vomiting? a. Myleran (busulfan) b. Chemet (succimer) c. Arimidex (anastrozole) d. Metozol (metoclopramide)
b. Heat stroke
On a hot, humid day, a client presents with a body temperature of 40.9°C (105.6°F), dry and flush skin, vomiting, low blood pressure, and muscle cramps. Which type of injury should the nurse suspect based on the manifestations? a. Malignant hyperthermia b. Heat stroke c. Hypothermia d. Normothermia
b. An unpleasant, subjective experience
Pain is best described as which of the following? a. A creation of a person's imagination b. An unpleasant, subjective experience c. A maladaptive response to a stimulus d. A neurologic event resulting from activation of nociceptors
d. "Hospice nurses are going to help care for him to make him more comfortable."
The family of a client diagnosed with cancer and entering hospice care has been informed the client is not expected to live more than 2 months. Which statement made by a family member indicates to the nurse that the family understands the role of hospice care? a. "Hospice nurses are going to help care for him at home until he gets better." b. "Hospice nurses are going to help care for him until we learn how to provide the care." c. "Hospice nurses are going to help care for him until he can take care of himself." d. "Hospice nurses are going to help care for him to make him more comfortable."
c. A combination of treatment modalities is effective for controlling many cancers
The goals of cancer treatment are based on the principle that... a. Surgery is the single most effective treatment for cancer b. Initial treatment is always directed toward cure of the cancer c. A combination of treatment modalities is effective for controlling many cancers d. Although cancer cure is rare, quality of life can be increased with treatment modalities
b. Give as needed pain medication
The home health nurse visits a 40-yr-old patient with metastatic breast cancer who is receiving palliative care. The patient has pain at a level of 7 (0-10 point scale). In prioritizing activities for the visit, what should the nurse do first? a. Auscultate for breath sounds b. Give as needed pain medication c. Check pressure points for skin breakdown d. Ask family about patient's food and fluid intake
d. Use a central venous access device
The most effective method of administering a chemotherapy agent that is a vesicant is to give it via which route? a. Give it orally b. Give it intraarterially c. Use an Ommaya reservoir d. Use a central venous access device
d. Nausea and vomiting can usually be managed with antiemetic drugs, diet modification, and other interventions
The nurse counsels the patient receiving radiation therapy or chemotherapy that a. Effective birth control methods should be used for the rest of the patient's life. b. After successful treatment, patients can expect a return to their previous level of function c. The cycle of fatigue-depression-fatigue that may occur during treatment may be reduced by restricting activity d. Nausea and vomiting can usually be managed with antiemetic drugs, diet modification, and other interventions
b. Requires the use of radioactive precautions during nursing care **brachytherapy is a type of radiation
The nurse explains to a patient undergoing brachytherapy of the cervix that she must do which of the following? a. Must undergo simulation to locate the treatment area b. Requires the use of radioactive precautions during nursing care c. May have desquamation of the skin on the abdomen and upper legs d. Requires shielding of the ovaries during treatment to prevent ovarian damage
b. Absence of sweating
The nurse is assessing a client diagnosed with heat stroke. Which clinical manifestation should the nurse expect? a. Pale and clammy skin b. Absence of sweating c. Nausea and vomiting d. Pharyngitis
d. Shivering **to generate heat again
The nurse is assessing a client who fell into a cold lake. Which assessment finding indicates that the client's body is attempting to regulate its temperature? a. Sweating b. Sleepiness c. Thirst d. Shivering
d. Let her communicate about the meaning of this experience
The nurse is caring for a 59-year-old woman who had surgery 1 day ago to remove an ovarian cancer mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The most effective nursing intervention at this point is to use this opportunity to do what? a. Motivate change from her unhealthy lifestyle b. Teach her about the 7 warning signs of cancer c. Discuss healthy stress relief and coping practices d. Let her communicate about the meaning of this experience
c. "Can you tell me what has been helpful to you in the past when coping with stressful events?"
The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information? a. "How long ago were you diagnosed with this cancer?" b. "Do you have any concerns about body image changes?" c. "Can you tell me what has been helpful to you in the past when coping with stressful events?" d. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"
b. Assess the pin sites **for signs of infection
The nurse is providing care for a 13-year-old who was placed in a halo brace within the last 24 hours because of a spinal cord injury. Which assessment is the first priority of the nurse? a. Loosen the connections on the vest to assess the skin b. Assess the pin sites c. Ask how the client is able to reposition self in bed d. Ask about the client's ability to perform range of motion to legs
a. Prepare the body to look as clean and natural as possible d. Remove the external tubes and drains
The nurse is providing postmortem care for a client. Which intervention would be appropriate prior to allowing the family to visit? (Select all that apply) a. Prepare the body to look as clean and natural as possible b. Keep the sheet over the client's face until the family is comfortably seated in the room c. Wear sterile gloves to pack the anal canal with gauze d. Remove the external tubes and drains e. Call the healthcare provider to verify time of death before taking the body to the morgue
b. "Palliative care will help with my pain and symptoms"
The nurse is talking to the patient who has just been diagnosed with cancer about considering palliative care. What verbalization by the patient would let the nurse know that patient understood palliative care? a. "Palliative care is the same as hospice care" b. "Palliative care will help with my pain and symptoms" c. "Palliative care only considers my goals for my care, not my families" d. "My doctor will provide all of the aspects of my palliative care"
c. Contractures, obesity, and pulmonary infections
The nurse is teaching the parents of a child with muscular dystrophy. The nurse should tell them that some of the progressive complications include which of the following? a. Dry skin and hair, hirsutism, protruding tongue, and mental retardation b. Anorexia, gingival hyperplasia, and dry skin and hair c. Contractures, obesity, and pulmonary infections d. Trembling, frequent loss of consciousness, and slurred speech
d. White blood cell (WBC) count of 2700/µL **low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. Hematocrit of 30% b. Platelets of 95,000/µL c. Hemoglobin of 10 g/L d. White blood cell (WBC) count of 2700/µL
b. Muscle rigidity
The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation? a. Hypocapnia b. Muscle rigidity c. Decreased body temperature d. Confusion upon arousal from anesthesia
a. "Muscular dystrophies usually result in progressive weakness." e. "Your child may have pain in his legs with muscle weakness."
The parents of a preschooler diagnosed with muscular dystrophy are asking questions about the course of their child's disease. Which should the nurse tell them? (Select all that apply) a. "Muscular dystrophies usually result in progressive weakness." b. "The weakness that your child is having will probably not increase." c. "Your child will be able to function normally and not need any special accommodations." d. "The extent of weakness depends on doing daily physical therapy." e. "Your child may have pain in his legs with muscle weakness."
a. Respiratory diaphragmatic breathing
The patient was in a traffic collision and is experiencing loss of function below C4. Which effect must the nurse be aware of to provide priority care for the patient? a. Respiratory diaphragmatic breathing b. Loss of all respiratory muscle function c. Decreased response of the SNS d. GI hypomobility with paralytic ileus and gastric distention
d. Ipsilateral proprioception loss below lesion
The rehabilitation nurse is admitting a client following spinal cord injury. The nurse concludes that the client has developed Brown-Séquard syndrome after detecting which assessment finding in the client? a. Ipsilateral motor loss above the lesion b. Contralateral loss of proprioception c. Hyperanesthesia below the level of the lesion d. Ipsilateral proprioception loss below lesion
a. Cells lack contact inhibition. c. Cells return to a previous undifferentiated state.
What features of cancer cells distinguish them from normal cells? (Select all that apply) a. Cells lack contact inhibition b. Cells undergo rapid proliferation c. Cells return to a previous undifferentiated state d. Proliferation occurs when there is a need for more cells
a. The UAP assists the patient to use dental floss after eating **Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding
When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? a. The UAP assists the patient to use dental floss after eating b. The UAP adds baking soda to the patient's saline oral rinses c. The UAP puts fluoride toothpaste on the patient's toothbrush d. The UAP has the patient rinse after meals with a saline solution
d. Ineffective airway clearance related to cervical spinal cord injury
When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority? a. Impaired urinary elimination related to tetraplegia b. Risk for impaired tissue integrity related to paralysis c. Disabled family coping related to the extent of trauma d. Ineffective airway clearance related to cervical spinal cord injury
a. An 89-year-old client on a fixed income during cold winter months
Which client is at the greatest risk for hypothermia? a. An 89-year-old client on a fixed income during cold winter months b. A pregnant woman in her first trimester c. A worker who repairs industrial freezers d. A 3-hour-old infant swaddled in a blanket, wearing a hat, and being held by the mother
c. Bradycardia
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with an acute spinal cord injury? a. Hypertension b. Neurogenic spasticity c. Bradycardia d. Bounding pedal pulses
c. Elevate the head of the bed
Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? a. Urinary catheterization b. Check for bowel impaction c. Elevate the head of the bed d. Administer intravenous hydralazine
a. Headache and rising blood pressure
Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Decreased level of consciousness or hallucinations d. Abdominal distention and absence of bowel sounds
c. Severity of injury
Which of the following is NOT one of the 3 criteria involved in classifying a spinal cord injury? a. Mechanism of injury b. Level of injury c. Severity of injury d. Degree of injury
c. Urinary incontinence
Which of the following is the primary symptom of neurogenic bladder? a. Erectile dysfunction b. Urinary frequency c. Urinary incontinence d. Hydronephrosis
b. A 15-year-old female patient with a spinal cord injury at C7 **Patients who are at MOST risk for developing autonomic dysreflexia are patients who've experienced a spinal cord injury at T6 or higher
Which patient below is at MOST risk for developing a condition called autonomic dysreflexia? a. A 24-year-old male patient with a traumatic brain injury b. A 15-year-old female patient with a spinal cord injury at C7 c. A 35-year-old male patient with a spinal cord injury at L6 d. A 42-year-old male patient recovering from a hemorrhagic stroke
b. Itching c. Burning d. Shooting e. Shock-like
Which words are most likely to be used to describe neuropathic pain? (Select all that apply) a. Dull b. Itching c. Burning d. Shooting e. Shock-like
c. "The arms and legs become cool and more bluish in color. Breathing becomes irregular and shallow, and you may hear mucus in the throat. Pulse and blood pressure will decrease."
While the nurse is discussing a client's likely death with family members, one of the adult children asks, "We plan on taking turns being here for now, but we all want to be here at the time of mother's death. How can we tell when that time is close?" What is the nurse's best response? a. "Often, people become more lucid for a short time about an hour before death. They become more alert with clearer eyes and focus on faces. Call the others in at that time." b. "I wish I could tell you that there was a way to know. It could be minutes from now or another 3 days. One just never knows." c. "The arms and legs become cool and more bluish in color. Breathing becomes irregular and shallow, and you may hear mucus in the throat. Pulse and blood pressure will decrease." d. "You can expect muscles to become rigid, with staring eyes and mouth closed. The head is pulled back with neck rigidity. Don't be alarmed if you hear a death rattle in the throat."
a. Blood pressure 69/38 d. Heart rate 29 e. Warm and dry extremities h. Temperature 95 'F **Hallmark signs and symptoms of neurogenic shock are: hypotension, bradycardia, hypothermia, warm/dry extremities (this is due to the vasodilation and blood pooling and will be found in the extremities)
You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? (Select all that apply) a. Blood pressure 69/38 b. Heart rate 170 bpm c. Blood pressure 250/120 d. Heart rate 29 e. Warm and dry extremities f. Cool and clammy extremities g. Temperature 104.9 'F h. Temperature 95 'F
c. Keeping the patient's spine immobilized
You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority? a. Keeping the head of the bed greater than 45 degrees at all times b. Repositioning the patient every thirty minutes c. Keeping the patient's spine immobilized d. Avoiding log-rolling the patient during transport
b. A 42-year-old who has spinal anesthesia c. A 25-year-old with a spinal cord injury above T6
You're working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? (Select all that apply) a. A 36-year-old with a spinal cord injury at L4 b. A 42-year-old who has spinal anesthesia c. A 25-year-old with a spinal cord injury above T6 d. A 55-year-old patient who is reporting seeing green halos while taking Digoxin
b. Mean arterial pressure (MAP) 90 mmHg
Your patient in neurogenic shock is not responding to IV fluids. The patient is started on vasopressors. What option below, if found in your patient, would indicate the medication is working? a. Decreased CVP (central venous pressure) b. Mean arterial pressure (MAP) 90 mmHg c. Serum lactate 6 mmol/L d. Blood pH 7.20
c. Assess the patient's blood pressure
Your patient, who has a spinal cord injury at T3, states they are experiencing a throbbing headache. What is your NEXT nursing action? a. Perform a bladder scan b. Perform a rectal digital examination c. Assess the patient's blood pressure d. Administer a PRN medication to alleviate pain and provide a dark, calm environment
