HPA Exam 4

Annual digital examination after age 40

The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should a nurse recommend?

-Observe the client closely for signs and symptoms of bowel perforation. -Monitor vital signs frequently until they are stable. -Inform the client that there may be blood in the stool and to report excessive blood immediately.

A 53-year-old client undergoes colonoscopy for colorectal cancer screening. A polyp was removed during the procedure. Which nursing interventions are necessary when caring for the client immediately after colonoscopy? Select all that apply.

Maintain the patency of the girl's airway.

A camp nurse has been rushed to a playing field where a girl appears to be experiencing an anaphylactic reaction. The nurse has had the child rushed to the camp's infirmary. What action should the nurse prioritize in the immediate care of this child?

The need for the parents to carry an epinephrine pen

A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is the nurse's priority for health education?

0.4 mg

A child is undergoing skin testing for allergies. About 10 minutes after a scratch test with an allergen, the child develops signs and symptoms of anaphylaxis. The nurse prepares to administer epinephrine subcutaneously. The child weighs 88 pounds. The nurse would administer which dosage of epinephrine?

"I should have a mammogram at age 50, and then every 2 years until age 74."

A client asks the nurse how frequently she should have a mammogram. The nurse assesses that there is no family history of breast cancer and no risk factors with this particular client. Which statement by the client shows an understanding of the nurse's teaching regarding the frequency of mammograms?

Abdominal pain and hepatomegaly

A client has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the client may have developed liver metastases?

The low levels of blood perfusion that exist in breast tissue

A client has been diagnosed with breast cancer and the client has asked the care team why her own immune system did not eliminate the cancerous cells when they first emerged. What phenomenon should the nurse describe?

Groshong catheter tunneled under the subclavian vein

A client has been diagnosed with stage II breast cancer and will require 8 weeks of chemotherapy. Which intravenous access would the nurse anticipate?

Aspirin Citrus fruits Red meats

A client is being screened for colorectal cancer with the fecal occult test. The nurse instructs the client to avoid ingesting which items 3 to 7 days prior to the test? Select all that apply.

Administer epinephrine (adrenaline).

A client is transported to the emergency department in respiratory distress after eating peanuts. The following interventions are ordered by the health care provider. Which intervention should the nurse complete first?

administer antiemetics and dexamethasone as prescribed.

A client is undergoing treatment for metastatic colorectal cancer. The client's chemotherapeutic regimen includes oxaliplatin IV. The nurse is preparing to administer a scheduled dose, and should:

sigmoidoscopy

A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?

The consistency of stool and comfort when passing stool

A client tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?

Administration of an antihistamine.

A client who is experiencing pruritus after being bitten by a mosquito asks the nurse what the most effective treatment would be. The best response by the nurse is:

severe abdominal pain with direct palpation or rebound tenderness

A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?

Dryness of the oral mucosa and the throat

A patient with allergic rhinitis is prescribed an antihistamine. The nurse instructs the patient to suck on a sugarless hard candy to prevent which condition?

Memory T cells

A person has been exposed to a particular antigen and a now experiences a repeat exposure. What stimulates a quicker immune response?

Assess for signs and symptoms of anaphylaxis.

A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?

anorexia breast swelling

A client who is receiving external beam radiation therapy as part of her treatment for breast cancer comes to the clinic for a follow-up visit. The nurse determines that the client is experiencing side effects of the treatment based on which findings? Select all that apply.

"It must be hard to hear that prognosis. Would it help you to talk to me or the chaplain?"

A client with colorectal carcinoma is devastated after learning that the cancer has spread to the liver and lungs and the client has only a 5% chance of surviving for 5 years. Which comment by the nurse would best help the client cope with this news?

Perform a thorough pain assessment.

A client with long-term breast cancer who was recently enrolled in a hospice program demonstrates signs and symptoms of clinical depression. Which action by the hospice nurse is appropriate?

-The client has mouth pain resulting from stomatitis. -The client has alopecia

A client with metastatic breast cancer is undergoing chemotherapy. What adverse effects should the nurse identify as resulting from the drugs' lack of complete selective toxicity? (Select all that apply.)

-Puckering -Nipple retraction -Discharge

A female client tells the nurse she felt a lump in her breast during her last self-breast exam. Which additional manifestations of the lump correspond to a diagnosis of cancer? Select all that apply.

-Apologize for not asking the client prior to calling the physician. -Verify that the client understands the purpose of the NG tube. -Explore other options that would be acceptable to the client. -Educate the husband on the wife's right to refusal of care. -Document the client's wishes in the medical record. -Notify the health care provider of the client's wishes and decision.

A nurse is caring for an alert and oriented client with end-stage breast cancer who has been unable to eat for 4 days due to intractable nausea. The nurse calls the healthcare provider and obtains an order for an NG tube placement per the spouse's request. When the nurse brings the equipment to the room, the client turns to the spouse and states "I just told you that I don't want any tubes or feedings!" Using the ANA Code of Ethics for Nurses, place the nursing actions in sequential order (rank actions from first to last). All options must be used.

"This test detects heme, a type of iron compound in blood in the stool."

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide?

Type II

The type of hypersensitivity reaction that is mediated by IgG or IgM antibodies directed against target antigens on specific host cell surfaces or tissues is also known as which type of hypersensitivity reaction?

Massive swelling in her arm

A 45-year-old woman has a family history of breast cancer. She herself was diagnosed with breast cancer 2 months ago. During a routine visit, the physician informs her that she has to undergo radiation as soon as possible to avoid spreading of the cancer. Which symptom would prompt radiation therapy?

"While diet is thought to play a role in the development of colorectal cancer, the ultimate causes are largely unknown."

A 71-year-old male has been recently diagnosed with a stage III tumor of colorectal cancer, and is attempting to increase his knowledge base of his diagnosis. Which statement about colorectal cancer demonstrates a sound understanding of the disease?

Foods Medications Insect stings

A client has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the client's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply.

Test all stools for occult blood.

A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?

Abdominoperineal resection

A client is diagnosed with colon cancer, located in the lower third of the rectum. What does the nurse understand will be the surgical treatment option for this client?

the client's pregnant granddaughter

A client is receiving external-beam radiation therapy to the thoracic and lumbar spine because of metastatic breast cancer. Which people should be permitted to visit?

Once, approximately 24 hours after chemotherapy

A client with breast cancer is receiving chemotherapy as part of the treatment plan. The client develops neutropenia and is scheduled to receive pegfilgrastim (Neulasta). The nurse would expect this drug to be given at which time?

-deep vein thrombosis -hot flashes -cataract

A client with breast cancer is receiving tamoxifen. After teaching the client about this drug, the nurse determines that the teaching was successful when the client identifies that she is at increased risk for which conditions? Select all that apply.

pain on defecation

A client with colorectal cancer reports constipation. Which signs or symptoms accompany constipation?

Acknowledge the client's reluctance and initiate discussion of the factors underlying it.

A client's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the client has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation?

fine-needle aspiration

A nurse is caring for a client who reports a lump in the left breast. Which diagnostic test will the nurse prepare the client for?

Polyps

A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

-breast self-examination -clinical breast examination -mammography

A nurse is working with a community group to foster early detection of breast cancer. Which components would the group address? Select all that apply.

A 64-year-old female whose mother had colorectal cancer

Select the client at greatest risk for developing colorectal cancer.

The client is under significant psychosocial stress.

The nurse is assessing a client's risk for impaired immune function. What assessment finding should the nurse identify as a risk factor for decreased immunity?

"When was your last colonoscopy completed?"

The nurse is caring for a 67-year-old woman in the reproductive health clinic. Which question should the nurse be sure to include during health screening and counseling with this client?

Epinephrine (Adrenalin)

The nurse is caring for a client who appears to be developing anaphylactic shock. What drug does the nurse anticipate the health care practitioner will order to treat this condition?

It is the third most common cancer in the United States.

The nurse is conducting a community education program on colorectal cancer. Which statement should the nurse include in the program?

Colonoscopy

The nurse is conducting a community education program using the American Cancer Society's colorectal screening and prevention guidelines. The nurse determines that the participants understand the teaching when they identify that people over the age of 50 should have which screening test every 10 years?

Wearing a medical alert bracelet Avoiding allergens

The nurse is conducting discharge teaching for a client who is being discharged from the emergency department after an anaphylactic reaction to peanuts. Which education should the nurse include in the teaching? Select all that apply.

IgE

The parent of a child with allergies has been told the child will have a blood test done for immunoglobulin measurement. The nurse should tell the parent that which immunoglobulin will be tested?

60-year-old female who follows a diet low in fat and high in fiber 80-year-old male with a history of prostatitis

The public health nurse is facilitating a cancer screening in-service for colorectal cancer. Which clients present the fewest risk factors for colon cancer? Select all that apply.

age 50 and older a positive family history a history of inflammatory bowel disease

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.

presents with a rigid, board-like abdomen.

Which client requires immediate nursing intervention? The client who:

Anaphylaxis

Which condition is treated with an adrenergic agonist?

IgG

Which immunoglobulin (Ig) is the most abundant of circulating antibodies?

Change in bowel habits

Which is the most common presenting symptom of colon cancer?

-Client education and preparation for treatment -Promotion of positive body image -Relieving fear -Management of complications

Which nursing intervention(s) are related to a client with breast cancer? Select all that apply.

-Patient education -Promotion of a positive body image -Intravenous (IV) therapy -Incision care

Which nursing interventions related to a client with breast cancer are appropriate for a nurse working in a community-based setting and a hospital-based nurse? Select all that apply.

Borborygmus

Which term refers to intestinal rumbling?

Diphenhydramine (Benadryl)

While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?

Annual screening after the age of 50

One of the greatest causes of death in the United States and Canada is colon cancer. The nurse instructs the community on which of the following factors?

Change in bowel habits

The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

Angioedema

Which allergic reaction is potentially life threatening?

Familial polyposis

Which characteristic is a risk factor for colorectal cancer?

T lymphocyte

Which type of lymphocyte is responsible for cellular immunity?

A client with colorectal cancer who is pre-operative for a bowel resection

The hospital nurse is caring for a group of adult clients. For which client should the nurse most likely administer prophylactic anti-infectives?

-Increasing age -Family history -Obesity

What risk factors for breast cancer should a health care provider teach his or her clients? Select all that apply.

"Screening mammography and clinical exams are the cornerstones of breast cancer screening."

Staff at a women's health center are being briefed by their supervisor on the latest recommendations for breast cancer screening. Which guidelines should staff pass on to their clients?

-cardiac toxicity -vascular thrombosis

A nurse is assessing a client who is receiving immunotherapy as part of her treatment plan for breast cancer. The nurse would be alert for which potential side effects? Select all that apply

Jabs the autoinjector into the outer thigh at a 90-degree angle

After teaching a client how to self-administer epinephrine, the nurse determines that the teaching plan has been successful when the client demonstrates which action?

The child is approaching vascular shock and developing edema due to actions of IgE antibodies, situations that can be reversed by administration of epinephrine.

An elementary school student has a severe allergy to peanuts and is displaying the signs of anaphylactic shock after inadvertently eating a candy bar containing peanuts. Which statement best describes the child's current status and preferred treatment?

Epinephrine

Anaphylaxis kits for clients allergic to bee stings would contain which medication?

provide prognostic information.

For a cancerous tumor, a client must undergo modified radical mastectomy, which includes axillary node removal and immediate reconstruction. The nurse explains to the client that the axillary nodes will be removed to:

-A nurse provides nutrition for a client through a feeding tube. -A nurse places a No Smoking sign on the door of a client who is receiving oxygen. -A nurse includes family members in the care of a client. -A nurse helps a client focus on the client's strengths following a diagnosis of breast cancer. -A nurse prepares a room for a clerical visit requested by a client.

Place the following examples of interventions to meet human needs in order from the most basic, highe- priority needs to the lower-priority needs based on Maslow's hierarchy.

-Administration of bisphosphonates -Initiating falls prevention protocols -Preparing the client for radiotherapy

The nurse is planning care for a client with breast cancer and metastasis to bone who has been admitted for palliative care. What should the nurse include in the plan of care? Select all that apply.