exam 3 theory
A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?
assess for sensation and strength in the legs
The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?
blueberry yogurt
The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching?
the pt uses bacitracin-neomycin-polymyxin on minor abrasions
The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?
the skin around the incision is pale and cold when palpated
A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect?
thickening of the skin around the ankles
. The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?
a 24 yr old pt who received neck radiation and has blood oozing from the neck
A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate?
administer prescribed antiemetics 1 hour before the treatments
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis?
check the lips and oral mucous membranes
When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's most important action?
consult with a HCP about the need for further diagnostic testing
A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan?
hospitalization is required for several weeks after the stem cell transplant
A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed?
if the medication burns when I apply it, I will wipe it off
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?
stop the infusion if swelling is observed at the site
Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?
suggest use of a daily planner and encourage adequate rest and sleep
A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?
surgical excision
An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care?
teach the use of cold packs to reduce bruising and swelling
The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?
I will need follow up examinations for many years after treatment before I can be considered for a cure
A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
"Malignant tumors may spread to other tissues or organs."
The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment?
I rarely have the energy to get out of bed
Which information will the nurse include when teaching an older patient about skin care?
use warm water and a moisturizing soap when bathing
What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?
washe hands and properly dispose of soiled dressings
. A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?
would you like to talk about options for the care of your children
Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?
IL-2 enhances the bodys immunologic response to tumor cells
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?
Patient has crackles up to the midline posterior chest
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?
try to stay out of the direct sun between the hours of 10 am and 2PM
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis?
talk with the pt alone and ask about the bruising
. A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he does not know what to say to his wife. Which nursing diagnosis is appropriate for the nurse to add to the plan of care?
Dysfunctional family processes related to effect of illness on family members
The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed?
The patient applies a thick layer of the cream to the affected skin.
. There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening?
a 38 yr old with a 7 mm nevus on the face that has recently become darker
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem?
encourage the pt to purchase a wig or hat to wear when hair loss begins
The nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)?
erythema actinic keratosis
A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care?
establish time to take a short walk almost every day
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure?
have the pt use protective eyewear while receiving PUVA
. The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?
hematuria
A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?
i can buy aloe vera gel to use on my skin
A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy?
incisional biopsy
The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider?
increased carcinoembryonic antigen (CEA)
A 35-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain?
method of contraception used by the patient
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?
minimizing sun exposure reduces risk for a future BCC
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?
the UAP assists the pt to use dental floss after eating
The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?
the UAP stands by the patients bed for 30 minutes talking with the patient.
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?
the biopsy will help decide the treatment for my enlarged prostate
A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate?
the cancer involves only the cervix
The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?
the patient swims several days each week
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?
the patient's visitors bring fresh peaches
The nurse working in the dermatology clinic assesses a young adult female patient who has. severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin ?
the pt recently had an intrauterine device removed
A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?
the pt takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs
A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?
the pt uses a tanning booth weekly
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect?
thinning of the affected skin
The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer?
baked chicken
Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
administer patch testing to a pt with allergic dermatitis apply a sterile dressing after the HCP excises a mole
A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?
apply prescribed anesthetic gel to oral lesions before meals
The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time?
are you taking any medications
A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first?
ask the pat to describe the impact of psoriasis on quality of life
The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse's appropriate action?
ask the pt about a personal or family history of a type 2 diabetes
The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure?
assess the pt for evidence of liver disease
A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem?
avoid giving the pt foods that are strongly disliked
The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the need for psychologic support, which question by the nurse will provide the most information?
can you tell me what has been helpful to you in the past when coping with stressful events
The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan?
clean the infected areas with soap and water
External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?
clean the perineal area carefully after every bowel movement
The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?
cleaning the skin with antimicrobial soap
A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)?
cook food thoroughly before eating avoid public transportation such as buses talk to the oncologist before having any dental work
A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)?
cool wet cloths or compresses can be used to reduce itching take a cool or tepid bath several times daily to decrease itching
The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure?
cotton tipped applicators
The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?
crackles heard at the lung bases
A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?
decreasing the tumor size will improve the effects of other therapy
The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer?
discuss risks associated with cigarette smoking during each patient encounter
During a routine health exam a 40 yr old pt tells the nurse about a family history of colon cancer. Which action should the nurse take next?
obtain more info about the family history
The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)?
pap testing sunscreen use mammography colorectal screening
A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?
papular wheal-like lesions with white deposits on the hair shaft
Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?
petechiae on the chest and abdomen
A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take?
prepare the pt for a skin biopsy
. The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding?
press firmly on the lesion
After change-of-shift report on the oncology unit, which patient should the nurse assess first?
pt who is neutropenic and has a temperature of 100.5 F (38.1 C)
Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of concern to the nurse?
reports a history of allergic rashes
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?
rinse the mouth before and after each meal and at bedtime with a saline solution
During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?
risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis
The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider?
serum sodium of 126 mEq/L
The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?
shortness of breath
During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions?
symmetric
. When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first?
talk with the pt alone and ask about the bruising
Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection?
use a sunscreen with a high SPF when exposed to the sun
The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient's instructions?
your cheek area will be eroded and it will take several weeks to heal