Exam 5 - Cellular Regulation & Thermoregulation

Three days before surgery for a permanent colostomy because of cancer of the colon, a client is receptive to all procedures, responds pleasantly when approached, and does not question staff about interventions or care being received. Which conclusion should the nurse make based on these behaviors? A. The client has been fully informed about what to expect. B. The client is not verbalizing feelings about concerns. C. The client cannot accept the illness and the need for surgery. D. The client feels reassured by frequent contact with health care staff.

B. Both diagnosis of cancer and a colostomy drastically alter self-image and body image. People react differently to this stress, often finding it difficult to express their concerns verbally; however their actions may demonstrate awareness of the situation. - There is not enough information about expectations, is not accepting of the illness and the need for surgery, or is feeling reassured by health care members.

A school-aged child with acute lymphoid leukemia in neutropenia. Which etiology would the nurse recognize as the cause of the neutropenia? A. Internal bleeding B. Overwhelming infection C. Increaed immature cell growth D. Decreased intake of iron-rich nutrients

C. Extensive growth of lymphoblasts suppresses the usual growth of RBCs, WBCs, and platelets. - Internal bleeding does not cause neutropenia. Infection is a risk result, not the cause, or neutropenia. An iron-intake deficit will not result in neutropenia.

Which nursing interventions help prevent heat loss in newborns? Select all that apply. A. The nurse keep the newborn covered in warm blankets B. The nurse keeps the newborn under radiant warmer. C. The. nurse places the newborn on the mother's abdomen D. The nurse measures the newborn's temperature regularly E. The nurse encourages the mother to feed the newborn well to maintain the fluid balance

A. Newborns have impaired thermoregulation due to immaturity of the body systems. Therefore, the nurse performs interventions to prevent heat loss in the newborn. Covering the newborn with warm blankets helps to prevent heat loss. B. The nurse keeps the newborn under the radiant warmer to help maintain the body temperature. C. Placing the newborn on the mother's abdomen helps to promote warmth through skin-to-skin contact. - Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help to prevent heat loss.

The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? Select all that apply. A. " I had a late onset of menarche." B. "My first child was born when I was 32." C. "I noticed a slight discharge from a nipple." D. "I perform breast self-examinations frequently." E. "I consume two to four glasses of alcohol a day."

B, C, E

What information from a client's history should the nurse identify as risk factors for the development of colon cancer? Select all that apply. A. Hemorrhoids B. Increased age C. High-fiber diet D. Ulcerative Colitis E. Low hemoglobin level

B. - a slower fecal transit, which occurs with aging, may increase the risk of colon cancer D. - chronic irritation of the intestinal mucosa, such as that of ulcerative colitis, increases the risk of colon cancer. - hemorrhoids' are signs of constipation, high-fiber diet decreases the risk of colon cancer, and low Hgb is not a risk for colon cancer but may be a result of it and it's therapies.

Which response would a nurse give to a female client with cancer of the breast admitted for a lumpectomy to be followed by radiation who, while being admitted to ambulatory surgery by the nurse, has tears in her eyes and in a shaky voice says, "I can't believe this is happening"? A. "You can't believe this is happening?" B. "This must be a very scary time for you." C. "Do you have any questions at this time?" D. "Cancer of the breast has a high cure rate."

B. The response "This must be a very scary time for you" identifies the client's feelings and provides an opportunity for further discussion. - Although the response "You can't believe this is happening?" echoes the client's statement, it does not identify a feeling. The response "Do you have any questions at this time?" denies the client's feeling and focuses on the information; the client may be too emotionally distraught to be able to construct or verbalize questions. The response "Cancer of the breast has a high cure rate" provides false reassurance and cuts off communication.

Which explanation will the nurse provide to a client with cancer who develops pancytopenia during the course of chemotherapy and asks the nurse why this has occurred? A. "The medication used for chemotherapy interacted with other medications you're taking" B. "Lymph node activity is depressed by the radiation therapy used before chemotherapy" C. "Noncancancerous cells also are susceptible to the effects of chemotherapuetic medications" D. "Dehydration caused by N/V/D results in hemoconcentration"

C. - Chemotherapy causes pancytopenia (decreased levels of erthyrocytes, WBCs, and platelets) via bone marrow suppression because frequently dividing cells are vulnerable to the effects of chemotherapy - This is not caused by a medication interaction but is inherent in the mechanism of action of the chemotherapeutic medications. Depressed lymph node activity as a result of radiation therapy used before chemotherapy is not the cause for fewer erythrocytes, WBCs, and platelets. Although it is true that dehydration caused by N/V/D results in hemoconcentration, this does not explain pancytopenia

Which action will the nurse plan to take when an unresponsive adult is admitted to the E.D. on a hot, humid day, with hot, dry skin, respiratory rate of 36 breaths/min, and a HR of 128 beats/min? A. Offer cool liquids B. Suction the airway C. Remove the clothing D. Prepare for intubation.

C. The client history and assessment data indicate likely hyperthermia. Clothing retains body heat; clothing must be removed before other cool methods are employed to reduce body temperature - Offering fluids is contraindicated because the client is unresponsive. There are no data to indicate an immediate need for suctioning, although the nurse will monitor the client for inability to clear the airway. Although intubation may become necessary, it is not the initial action

Which type of fever does a client have when experiencing fever spikes combined with a normal body temperature occurring at least once a day? A. Sustained B. Relapsing C. Remittent D. Intermittent

D. - An intermittent fever is characterized by fever spikes interspersed with normal temperatures. In this type of fever, the body temperature returns to normal at least once in 24 hours. - In the case of sustained fever, there is a constant body temperature greater than 100.4 *F (38 *C). In relapsing fever, there is an occurrence of periods of febrile episodes with acceptable temperature values. In remittent fever, the body temperature increases and decreases without returning to normal body temperature levels.

Which causative agent is common for both hyperthermia and hypothermia? A. Alcohol B. Barbiturates C. Phenothiazines D. Cardiovascular disease

A. Alcohol is the causative agent that is common to both hyperthermia and hypothermia. - Barbiturates and phenothiazines can cause HYPOthermia. CVD can cause HYPERthermia.

Which common response do clients with cancer experience, regardless of the site of the cancer, that accounts for their cachexia? A. Depression precipitates anorexia B. Changes in taste and food aversions C. Decreased saliva impedes chewing and swallowing D. Decreased GI absorption of nutrients

B. This problem may occur even when nutritional intake appears adequate. Changes in taste resulting from the cancer or the treatment can reduce appetite and cause food aversion. Some clients experience early satiety or a sense of fullness and inability to eat.

Which activity places a client at risk for hyperthermia? A. Snowmobiling B. Skiing in the winter C. Hiking Alaskan mountains D. Performing strenuous activity in high humidity

D. When a client performs strenuous activity in high humidity, it reduces heat loss from the body and results in hyperthermia. - Activities such as snowmobiling, skiing, and hiking in cold weather cause hypothermia because they occur in cold temperatures and may lower the body temperature.

Which clinical manifestations does the nurse expect the client to report when admitted for surgical resection of a rectosigmoid colon cancer? Select all that apply. A. Feeling tired B. Rectal bleeding C. Inability to digest fats D. Change in shape of stools E. Feeling of abdominal bloating F. Stools float and are clay-colored

A. - Anemia may manifest as fatigue, feeling tired, and/or generalized weakness. Anemia is common with rectosigmoid colon cancer from the loss of blood rectally. B. - Passage of red blood (hematochezia) is one of the cardinal signs of rectosigmoid colon cancer; ulcerations of the tumor and straining to pass stool can precipitate rectal bleed. D. - A cancerous mass can grow into the lumen of the sigmoid colon, altering the shape of stool (ribbonlike or pencil thin) E. - Tumors in the rectosigmoid colon cause partial and eventually complete obstruction of the intestinal lumen. Because there is less fluid in the stool of the descending and sigmoid colon, a formed mass develops; thus, the client strain to pass stools, and gas pains (causing a feeling of abdominal bloating), cramping, and incomplete evacuation commonly occur. - an inability to digest fats is not specific to rectosigmoid colon cancer; therefore stools will not float and will contain bile, which colors the stool brown.

Which findings indicates that a client is at increase risk for color rectal cancer (CRC)? Select all that apply. A. Presence of dark, tarry stool B. Family history of polyposis C. 20-year history of ulcerative colitis D. Unintentional 20 lb weight loss E. Change in bowel patterns for 3 months

A. Dark, tarry stool occurs from occult blood loss B. Familial polyposis is a precursor to CRC C. Ulcerative colitis is an inflammatory bowel disease that increases clients risk for CRC D. Any client who experiences an unexplained and unintentional weight loss should be evaluated for cancer. E. A client who reports a longstanding change in bowel patterns should be tested for CRC.

After assessing the vital signs and medical history of a client admitted to the hospital experiencing chills and fever, the nurse concludes the fever patterns is remittent. Which assessment finding led to this conclusion? A. The client's temperature returns to an acceptable value at least once in the past 24 hours. B. The client's fever spikes and falls without a return to normal temperature levels. C. Periods of febrile episodes and periods with acceptable temperature values occur. D. The client has a constant body temperature continuously above 100.4 *F with minimal fluctuation.

B.

How will the nurse respond to a client with cancer experiencing severe nausea and vomiting from chemotherapy who wanted to know if it is true that smoking marijuana will help? A. "Nurses are not allowed to discuss illegal substances with clients." B. "Marijuana is effective for nausea and vomiting if it is injected." C. "Marijuana is not proven to be effective in preventing chemotherapy-induced nausea and vomiting." D. "Some tetrahydrocannabinol (THC)-based medications that contain marijuana control chemotherapy-induced nausea and vomiting in some people."

D. - THC, an ingredient in marijuana, acts as an antiemetic in some people and can be absorbed through the GI tract or inhaled. THC-based medications, dronabinol, and nabilone are available by prescription to control N/V resulting from cancer chemotherapy. - Nurses are not forbidden to talk about illegal issues and marijuana is prescribed legally in some states. Marijuana is not inject ever. THC is an effective antiemetic for some clients.

A newborn experiences a hypothermic period while being bathed and having clothes changed. Once the hypothermic episode has been identifies and treated, which is the next nursing action? A. Feeding the infant B. Requesting a complete blood count C. Monitoring the infant for hyperthermia D. Allow the infant to rest undisturbed

A. A newborn who experiences a hypothermic episode responds by becoming hypoglycemic; providing calories will increase the blood glucose level. - The blood count will not change during a transient hypothermic episode. If the hypothermic period is treat adequately, hyperthermia is not expected to develop. Allowing the infant to rest undisturbed will result in a delay in meeting the newborn's need for an increase in blood glucose.

An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature is 105 *F (40.6 *C), orally. Which condition would the nurse suspect? A. Heat stroke B. Heat exhaustion C. Accidental hypothermia D. Malignant hyperthermia

A. Older adults are more at risk of heat stroke. Symptoms of heat stoke include giddiness, excessive thirst, nausea, and increase body temperature. - Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95 *F (35*C), the client suffers from uncontrolled shivering, memory loss, depression, and poor judgement. Malignant hyperthermia is an adverse effect of inhalation anesthesia indicated by a sudden rise in body temperature in intraoperative or postoperative clients.

An adolesent with leukemia is to be given a chemotherapeutic agent. Which time is best for the nurse to administer the prescribed antiemetic? A. As nausea occurs B. An hour before meals C. Just before each meal is eaten D. Before each dose of chemotherapy

D. - The purpose of an antiemetic before chemotherapy is to prevent the child from experiencing nausea during and after the administration of the medication. - Waiting until nausea has occurred is too late; the medication should be given before nausea occurs. The meals are not causing the nausea; the nausea is caused by the chemotherapy, and if nausea is not prevented, the child will not eat.

Which value is most likely to be the core body temperature of the hypothermic victim brought to the E.D. in whom shivering is diminished or absent? A. 104 *F (40 *C) B. 95 *F (35 *C) C. 89.6 *F (32 *C) D. 82.4 *F (28 *C)

D. Severe hypothermia occurs at core body temperatures equal to or below 86 *F (30 *C). At a body temperature of 82.4 *F (28 *C), the client would be severally hypothermic; this state is likely to be characterized by diminished or absent shivering. - At body temperatures of 95 *F (35 *C) and 89.6 *F (32 *C), clients would have mild and moderate hypothermia, respectively. Both mild and moderate hypothermia are likely to be characterized by shivering.

At which body temperature does the BP of a victim of hypothermia become obtainable only by Doppler? A. 91.4 *F (33 *C) B. 95 *F (35 *C) C. 96.8 *F (36 *C) D. 98.6 *F (35 *C)

A. The BP of a victim of moderate hypothermia is obtainable only by a Doppler. Moderate hypothermia occurs when the client's core temperature is between 30 *C (86 *F) and 33.9 *C. (93.2 *F). The victim of hypothermia with a core body temperature of 33 *C (91.4 *F) is likely to have the BP obtainable only by Doppler. - Mild hypothermia occurs when the core body temperature is between 34 *C (93.2 *F) and 36 *C (96.8 *F). These clients (here, with body temperatures 35 *C [95 *F] and 36 *C [96.8 *F]) have only minor heart rate changes and their BP does not need to be obtained by Doppler. A core body temperature of 37 *C (98.6 *F) is in the normal range; it does not denote hypothermia.

The mammography results for a 37-year-old client, with a breast mass, are inconclusive. The client is undergoing further diagnostic tests to determine whether the mass is malignant. Which information would the nurse take into consideration before planning health teaching for this client? A. Squamous cell carcinomas are neoplasms arising from glandular tissues B. Results of a biopsy are necessary befoe a specific form of therapy is selected C. Mammograms should be repeated to confirm the presence of malignancies D. Waiting for severeal weeks before receiving confirmation of cancer is helpful to the client

B. The specific therapy selected depends on whether there is a malignancy and, if so, the type of cancer cells, the extent of nodal involvement, and the presence and extent of metastasis. Only a biopsy will confirm the diagnosis of a malignancy. - Adenocarcinomas, not squamous cell carncinomas, arise from grandular tissue; squamous cell carcinomas arise from epithelial tissue. Repeating a mammogram would only delay diagnosis. Waiting several weeks for a diagnosis is not advisable; an extended waiting period increases the client's stress and anxiety.

The nurse obtains the history of a client with early colon cancer. Which clinical finding does the nurse consider consistent with a diagnosis of cancer of the descending, rather than the ascending, colon? A. Pain B. Fatigue C. Anemia D. Obstruction

D. Signs and symptoms of obstruction occur earlier with cancer in the descending colon because the consistency of the stool is formed rather than liquid. - Pain, a late symptom of colon cancer, may occur regardless of the location of the primary lesion. Fatigue occurs in colon cancer regardless of primary site; it is related to anorexia, weight loss, and anemia. Bleeding, which results in anemia occurs in colon cancer regardless of primary site because the lesions extend into the intestinal mucosa.

Which preventative wellness recommendation will the nurse make to a male client who tests positive for the BRCA mutation after his mother and two sisters are found to carry the gene? Select all that apply. A. Get a baseline mammogram at 40 years B. Get prostate screening starting at the age of 50 C. Get breast self-examination (BSE) training at 35 years D. Get a clinical breast examination (CBE) every 6 months starting at 35 years E. Get a clinical breast examination every 6 months starting at 40 years

A, C, D. - A male client that tests positive for the BRCA mutation should get a baseline mammogram at 40 years, be provded BSE training at 35 years, and get a CBE every 6 months starting at age 35. - Prostate scrrening should be initiated at 40 years, not 50.

The nurse assesses for which client symptoms that indicate hyperthermia? Select all that apply. A. Vasodilation B. Dry and flushed skin C. Pale and cyanotic skin D. Decreased capillary refill E. Decreases urinary output

A,B. During hyperthermia, vasodilation occurs that causes the flushed appearance of the skin; as a result the skin may be warm to the touch B,D. Hypothermia cause loss of water from the body and results in dry skin and mucous membranes, decreased urinary output, and other signs of dehydration and electrolyte imbalance. - Clients with hyperthermia may not have pale and cyanotic skin; instead, they have dry, flushed skin. Client with hyperthermia may not have decreased capillary refill; instead, they have increased capillary refill.

While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures. These episodes are longer than 24 hours. Which fever pattern would the nurse anticipate? A. Relapsing B. Sustained C. Remittent D. Intermittent

A.

Which risk factor would the nurse discuss with a local womens' group as indicating the need for breast cancer screening at an earlier age? A. Family history of breast cancer B. History of tobacco use C. Obesity D. Early onset menopause

A. A family history of breast cancer increase one's risk; thus screening should begin earlier (around age 30). - Tobacco use and obesity may increase the risk for breast cancer but do not necessarily indicate the need to begin breast cancer screening at an earlier age. Late, not early, onset menopause is a risk factor for breast cancer, but it does not indicate the need to begin breast cancer screening at an earlier age.

Which client would the nurse instruct to limit their number of visitors as a safety priority? A. Client going under brachytherapy B. Client undergoing prostate surgery C. Client who underwent uterine artery embolization D. Client who underwent open spinal reconstructive surgery for scoliosis

A. Brachytherapy for breast cancer contains radiation in a temporary implant. Client A, who is undergoing brachytherapy, is instructed to limit the number of visitors as a safety precaution. - Client B, who is undergoing prostate surgery, is monitored closely for signs of infection as a nursing safety priority. Client C, who underwent uterine artery embolization, may have severe cramping, and the pain level assessed. Client D, who underwent an open spinal reconstructive surgery for scoliosis, is assessed for respiratory status.

A client is admitted for a biopsy of a tumor in her left breast. The client states, "I know it can't be cancer, because it doesn't hurt." Which response by the nurse is the most therapeutic? A. "Let's hope that it isn't malignant." B. "What do you know about breast cancer?" C. "Most lumps in the breast are not malignant." D. "Has you primary health care provider told you that it wasn't cancer?"

B. - Asking what the client knows about breast cancer allows the nurse to asses the client's understanding of breast cancer and to clarify any misconceptions. -Saying that they should hope that the growth isn't malignant avoids an opportunity to teach, and it is a type of false reassurance. The statement may actually increase feelings of hopelessness if the lesion is determined to be malignant. Although correct, stating that most lesions are not malignant provides a false sense of security and avoids an opportunity to teach. Asking whether the primary health care provider has told the client that it wasn't cancer focuses on what the primary health care provider said rather than what the client knows and may limit further communication of feelings and beliefs.

Which interventions would the nurse implement to prvent infection in preschool child with acute nonlymphoid leukemia who is admitted with a fever and neutropenia? A. Placing the child in a private room, restricting ill visitors, and using strict hand-washing techniques B. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion C. Avoiding taking rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture D. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and provdiing frequent saline mouthwashes

A. Children with leukemia most odten die of infection; a low neutrophil count is associated with myelosuppressant therapy. Place the child in a private room, restricting ill visitors, and using strict hand-washing techniques are the best ways to minimize complications. - "Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion" are not appropriate measures to prevent infection result from neutropenia; they are appropriate for treating the anemia. "Avoiding taking rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture" are not appropriate measures to prevent infection resulting from neutropenia; they are more appropriate for preventing bleeding. "Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and provdiing frequent saline mouthwashes" are not appropriate measures to prevent infection resulting from neutropenia; they are used to ease and treat stomatitis.

Which is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the E.D.? A. Warming the newborn B. Clamping the umbilical cord C. Assessing maternal bleeding D. Monitoring expulsion of the placenta

A. Immature thermoregulation necessitates warming the newborn to prevent neonatal hypothermia. - The cord may be left intact until the newborn's temperature is stabilized, after which it may be clamped. It is too soon to evaluate the hemorrhagic condition of the mother; the placenta has not yet been expelled. The expulsion of the placenta is not a concern; it may not separate for 30 minutes.

The nurse is caring for a child undergoing chemotherapy for acute lymphoid leukemia. The parent asks why the child needs prednisone. Which response by the nurse would be correct? A. "It decreases inflammation" B. "It suppresses the production of lymphocytes" C. "It increases appetite and the a sense" D. "It may decrease skin irritation and edema"

A. Prednisone is a synthetic glucocorticoid that exerts an active anti-inflammatory effect by stablizing lysosomal membranes, thereby inhibiting proteolytic enzyme release. - Prednisone does not affect the lymphocytes. Although prednisone increases the appetite and creates a sense of well-being, these are not the reasons it is administered. There is no indication the child is receiving radiation.

The client is on neutropenic precautions. From which direction does the protective environment isolation help prevent the spread of infection? A. To the client from outside sources B. From the client to others C. From the client by using special techniques to destroy infectious fluids and secretions D. To the client by using special sterilization techniques for linens and personal items

A. Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents beauce the client's own immune ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation.

Which instruction would the nurse provide to a client who would like to learn breast self-examination? A. Squeeze the nipples to examine for discharge. B. Use the right hand to examine the right breast C. Perform the examination while in a seated position D. Compress the breast tissue to the chest wall with the palm to palpate for lumps

A. Serous or bloody discharge from the nipple is pathological and must be reported. - The right hand should be used to examine the left breast because it allows the flattened fingers to palpate the entire breast, including the tail (upper, outer quadrant toward the axilla) and the axillary area. The examination is best before while lying down to allow the fingers to more easily compress the breast tissue. The flat part of the fingers, not the palm or fingertips, should be used for palpation. Although breast self-examination is no longer routinely recommended by the ACS and other organizations, some clients wish to learn the technique as part of self-breast awareness, which is recommended.

Which signs and symptoms would the nurse expect when assessing a 4-year-old child with newly diagnosed acute lymphocytic leukemia (ALL)? Select all that apply. A. Edema B. Alopecia C. Anorexia D. Insomnia E. Petechiae

Anorexia occurs as a result of catabolic alterations of metabolism caused by the cancer. Bone marrow depression (also caused by the cancer) will reduce the platelt count, which results in bleeding tendencies, petechiae, and ecchymoses. - The RBC is also reduced as a result of bone marrow depression, so the child will be lethgargic and sleep excessively. Edema is not expected during early-stage actue lymphocytic leukemia (ALL), and alopecia occurs because of chemotherapy, not the disease process.

A client has a platelet count of 49,000/mL (49 x 10^9/L). The nurse would instruct the client to avoid which activity? A. Ambulation B. Blowing the nose C. Visiting with children D. Eating fresh fruits and vegetables

B. Clients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse should instruct the client to avoid blowing their nose, because this activity can increase the risk of bleeding. - Ambulation and visiting with children are not contraindicated with thrombocytopenia. Fresh fruit and vegetables are contraindicated for neutropenia, not thrombocytopenia.

The nurse expects a client with an elevated temperature to exhibit which indicator of pyrexia? Select all that apply A. Dyspnea B. Flushed face C. Precordial pain D. Increased pulse rate E. Increased BP

B. Increased body heat dilates blood vessels, causing a flushed faces. D. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. - Fever may not cause difficulty breathing. Pain is not related to fever. BP is not expected to increase during fever.

Which condition would the nurse keep in mind while performing a rewarming procedure for a client with severe hypothermia? A. The client is at risk for hypertension from rewarming shock. B. The client should be monitored for after drop during rewarming. C. The cold myocardium should be stimulated a in hypothermic client. D. The core of the client with severe hypothermia should be warmed after the extremities.

B. Rewarming places the client at risk for after drop, a further drop in core temperature. This occurs when cold peripheral blood return to the central circulation. So, the core temperature of the client should be monitored carefully during rewarming. - Rewarming shock can produce HYPOtension, not hypertension. The cold myocardium is extremely irritable, making it vulnerable to dysrhythmias. Gentle handling is essential to prevent the myocardium from be stimulated at all. Clients with moderate to severe hypothermia should have the core temperature warmed before the extremities to prevent rewarming shock.

The client with which core body temperature would require priority critical care? A. 30 *C B. 27 *C C. 32 *C D. 29 *C

B. Severe hypothermia, or a core body temperature below 82.4 *F (28 *C), can cause cardiac arrest. The client with a core body temperature of 27 *C should be treat first to ensure safety. - Clients with moderate hypothermia (82.4 *F-90 *F [28 *C-32*C]) are at lesser risk for cardiac arrest than a client with severe hypothermia. Clients with a core body temperature of 30 *C, 32 *C, and 29 *C can be treated after treating the client with a core body temperature of 27 *C.

A postmenopausal client with cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she is not feeling well. The nurse reviews the medical record data presented in the image. After analysis of the available history, laboratory tests, and clinical manifestations, which goal has the highest priority for this client? Medications: - Cyclophosphamide - Doxorubicin - Fluorouracil Lab Results: - RBC: 4.2 u: - WBC: 3000 uL - Hgb: 12.5 g/dL - Hct: 39% - Platelets: 190,000 uL Vital Signs: - Temperature (oral): 99.8 *F - Pulse 88 bpm - Respirations: 24 breaths/min - BP: 126/88 mm Hg A. Promote rest B. Prevent infection C. Avoid bodily harm D. Maintain fluid balance

B. The prevention of infection is the priority because an infection can be life-threatening for an immunocompromised client. Chemotherapeutic medications depress the bone marrow, causing leukopenia. The client's WBC is below the expected range of 4500 to 11,000/mm^3 (4.5 to 11 x 10^9/L) for an older female adult. - Although the elevation in the client's temperature, pulse, and respirations may relate to the direct effects of the chemotherapuetic agents, they also may reflect the client resisting a microbiologic stress. Althhough a balance between rest and activity is important, it is not the priority. Even though preventing injury is important, it is not the priority. Although maintaining fluid balance is important, it is not the priority. The client's Hct is within the expected range of 36% to 42% for women, indicating that the client is not dehydrated. A decrease BP indicates dehydration of fluid volume deficit; however, the client's BP is within acceptable limits. Although chemotherapuetic medications may cause N/V/D, the client did not indicate these clinical manifestations occured.

Which action would a nurse take to avoid complications in a client who has developed severe bone marrow depression after receiving chemotherapy for cancer? Select all that apply. A. Monitor for signs of alopecia B. Encourage an increase in fluids C. Wash hands before entering the client's room D. Advice use of a soft toothbruch for oral hygiene E. Report an elevationin temperature immediately F. Teach the client to avoid eating raw fruits or vegetables

C, D, E. - Bone marrow depression causes neutropenia; it is essential to prevent infection in this client by thorough hand washing before touching the client or client's belongings. Thrombocytopenia occurs with chemotherapy induced bone marrow depression; using a soft toothbrush helps prevent bleeding gums. Any temperature elevation in a client with neutropenia must be reported to the primary health care provider immediately because it may be a sign of infection. - Although alopecia does occur with chemotherapy, it is not related to bone marrow suppression. Increasing fluids will neither reverse bone marrow suppression nor stimulate hematopoiesis. Clients who have neutropenia may eat raw fruits and vegetables after washing off soil that may contain disease-causing microbes.

The nurse finds the client's fever spikes and falls without a return to normal level. Which pattern of fever is this a characteristic? A. Relapsing B. Sustained C. Remittent D. Intermittent

C.

Which is the correct response to a parent whose child is undergoing chemotherapy and is not up to date of required immunizations for school? A. By this time your child has developed sufficienct antibodies to provide immunity B. Maintaining current immunizations is critical. Make sure the series is completed C. This isn't the best time to finish the immunizations, because you child's immune system is suppressed D. It's important to complete the immunizations because your child needs to be protected from childhoof

C. - Chemotherapy compromises this immune system. The vaccines may be administered after the completion of the chemotherapy protovol, once the immune system has returned to its previous state. - The child has not developed sufficient antibodies; booster immunizations are needed, but not at this time. Administering immunizations at this time could prove fatal.

Which instruction would the nurse provde a client with leukopenia secondary to chemotherapy? A." You should avoid exposure to the sun and use a sunscreen" B. "You should eat high-fiber foods and increase fluid intake" C. "You should avoid large crowds and people with infections" D. "You should consume iron supplements and erythropoietin."

C. - Leukopenia consists of low levels of WBCs. A leukopenic client should avoid large crowds and people with infection because the client may contract an infection as a resilt of compromised immunity. - The suggestion of avoiding exposure to the sun and using a sunscreen would be beneficial for a client with chemotherpay-induced skin changes. The suggestion of eating high-fiber foods and increasing fluid intake would be beneficial for a client with constipation after chemotherapy. Consuming iron supplements and erythropoietin would be required for a client who developed anemia after chemotherapy.

Which systemic side effect would the nurse monitor for in a client receiving combination chemotherapy for the treatment of metastatic carcinoma? A. Ascites B. Nystagmus C. Leukopenia D. Polycythemia

C. - Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppresion. - Ascites is not a side effect of chemotherapy. Chemotherapy does not affect the eyes; nystagmus is an involuntary, rapid rhythmic movement of the eyeballs. Also, nystagmus is a local, not systemic, response. The RBCs will be decreased, not increased.

A 28-year-old woman is diagnosed as having cancer of the left breast. A simple mastectomy is performed. Which action would be included in the plan of care immediately after surgery? A. Changing the client's pressure dressing if necessary B. Inviting a Cancer Society volunteer to visit the client C. Placing the client in the semi-Fowler position with the left arm elevated D. Waiting for cessation of drainage before the client resumer any activity

C. - The semi-Fowler position and elevation of the arm of the affecter side minimizes edema related to the inflammatory process. - Pressure dressing are rarely used because portable would drainage systems are used to remove accumulated fluid from the surgical site. A Cancer Society volunteer will not visit on the day of the surgery; the visit will probably be made in the client's home. ADLs that necessitate only slight flexion of the elbow and do not involve abduction of the arm on the affected side are allowed.

Which statement made by a 70-year-old female client about changes caused by aging indicates effective learning? A. "I should reduce my calcium intake" B. "I should limit my Kegel exercises" C. "I should have regular breast examinations" D. "I should avoid eating protein"

C. A 70-year-old female regular clinical breast examinations to detect masses or other changes that may indicate the presence of cancer. - The clients should take an adequate amount of calcium to prevent osteoporosis. Performing Kegel exercises strengthens pelvic muscles and reduces urinary incontinence. Protein is needed to maintain muscle mass and strength.

The nurse is teaching a woman how to perform breast self-examinations . Which statement indicated that the client requires further eduction? A. "I examine my breast about a week after my period starts" B. "I've been looking for dimpling and checking for lumps" C. "My breasts are so tender right before my period that I hate doing it" D. "My grandmother examines her breast on the first Monday of each month"

C. BSEs should be performed about a week after menstration, when the breasts are less engorged and tender. - Menstruating women should examine their breats about a week after the period starts. Dimpling may occur when a tumor attaches to the skin or underlying tissue and should be reported. After menopause, selection of a specific time each moth for BSE reduces the possibility of forgetting.

The nurse is measuring the body temperature of four neonates at term in a pediatric health setting. Which neonate has a normal body temperature? A. Neonate 1 - 35.5 *C B. Neonate 2 - 36 *C C. Neonate 3 - 37.1 *C D. Neonate 4 - 38.5 *C

C. The normal body temperature of term neonates is in the range of 36.5 *C to 37.5 *C. A body temperature of 37.1 *C is a normal finding. - The body temperatures of neonates 1 and 2 indicate hyperthermia. The body temperature of 38.5 *C in neonate 4 indicates hyperthermia.

The nurse concludes that a client with a body temperature of 98.6 *F (37 *C) is experiencing which condition? A. Hypothermia B. Hyperpyrexia C. Hyperthermia D. Normothermia

D. A body temperature of 98.6 *F is normal. The nurse concludes that the client is normothermia. - The client does not have a low body temperature or hypothermia. The client's body temperature does not exceed the normal range; therefore, the client does not have hyperpyrexia or hyperthermia.