Med/surg test 3 prepu chapter 15
A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is
"You will need to practice birth control measures." Explanation: Following chemotherapy female clients may experience normal ovulation, early menopause, or permanent sterility. Clients are advised to use reliable methods of birth control until reproductivity is known.
A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis is appropriate for this client?
Anticipatory grieving Explanation: Anticipatory grieving is an appropriate nursing diagnosis for this client because few clients with gallbladder cancer live more than 1 year after diagnosis. Impaired swallowing isn't associated with gallbladder cancer. Although surgery typically is done to remove the gallbladder and, possibly, a section of the liver, it isn't disfiguring and doesn't cause Disturbed body image. Chronic low self-esteem isn't an appropriate nursing diagnosis at this time because the diagnosis has just been made.
Which of the following occurs when there is accumulation of fluid in the pericardial space that compresses the heart?
Cardiac tamponade Explanation: Cardiac tamponade is an accumulation of fluid in the pericardial space. SVCS occurs when there is a compression or invasion of the superior vena cava by a tumor, enlarged lymph nodes, intraluminal thrombosis that obstructs venous circulation, or drainage of the head, neck, arms, and thorax. SIADH is the continuous, uncontrolled release of ADH. DIC is a complex disorder of coagulation or fibrinolysis which results in thrombosis or bleeding.
A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?
Extravasation Explanation: The client is exhibiting signs of extravasation, which occurs when the medication leaks into the surrounding tissues and causes swelling, burning, or pain at the injection site. Erythema is redness of the skin that results from skin irritation. Flare is a spreading of redness that occurs as a result of drawing a pointed instrument across the skin. Thrombosis is the formation of clot within the vascular system.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift Explanation: Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?
Monitor the client closely to prevent infection. Explanation: Until transplanted stem cells begin to produce blood cells, these clients have no physiologic means to fight infection, which makes them very prone to infection. They are at high risk for dying from sepsis and bleeding before engraftment. Therefore, a nurse must closely monitor clients and take measures to prevent infection.
A patient with brain tumor is undergoing radiation and chemotherapy for treatment of cancer. Of late, the patient is complaining of swelling in the gums, tongue, and lips. Which of the following is the most likely cause of these symptoms?
Stomatitis Explanation: The symptoms of swelling in gums, tongue, and lips indicate stomatitis. This usually occurs 5 to10 days after the administration of certain chemotherapeutic agents or radiation therapy to the head and neck. Chemotherapy and radiation produce chemical toxins that lead to the breakdown of cells in the mucosa of the epithelium, connective tissue, and blood vessels in the oral cavity.
The clinic nurse is caring for a client who has just been diagnosed with a tumor. The client says to the nurse "The doctor says my tumor is benign. What does that mean?" What is the nurse's best response?
"Benign tumors don't usually cause death." Explanation: Benign tumors remain at their site of development. They may grow large, but their growth rate is slower than that of malignant tumors. They usually do not cause death unless their location impairs the function of a vital organ, such as the brain. (less)
A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?
"I floss my teeth every morning." Explanation: A client with a platelet count of 30,000/mm3 is at risk for bleeding and shouldn't floss his teeth. Flossing may increase the risk of bleeding in a client with a platelet count less than 40,000/mm3. Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving. Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.
During a client's examination and consultation, the physician keeps telling the client,"You have an abdominal neoplasm." Which of the following statements accurately paraphrases the physician's statement? Select all that apply.
"You have a new growth of abnormal tissue in your abdomen." • "You have an abdominal tumor." Explanation: New growths of abnormal tissue are called tumors. Tumors may be benign or malignant; not all tumors are cancerous.
Which of the following is a sign or symptoms of septic shock?
Altered mental status Explanation: Signs of septic shock include altered mental status, cool and clammy skin, decreased urine output, and hypotension.
Which of the following is a type of procedure that uses liquid nitrogen to freeze tissue that causes cell destruction?
Cryoablation Explanation: Cryoablation uses liquid nitrogen or a very cold probe to freeze tissue to cause cell destruction. Electrosurgery, chemosurgery, and laser surgery do not use liquid nitrogen to freeze tissue.
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?
Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Explanation: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.
Which primary cancer treatment goal is prolonged survival and containment of cancer cell growth?
Control Explanation: The range of possible treatment goals may include complete eradication of malignant disease (cure), prolonged survival and containment of cancer cell growth (control), or relief of symptoms associated with the disease (palliation).
The drug interleukin-2 is an example of which type of biologic response modifier?
Cytokine Explanation: Other cytokines include interferon alfa and filgrastim. Monoclonal antibodies include rituximab, trastuzumab, and gemtuzumab. Retinoic acid is an example of a retinoid. Antimetabolites are cell cycle-specific antineoplastic agents.
You are an oncology nurse caring for a client who tells you that their tastes have changed. They go on to say that "meat tastes bad". What is a nursing intervention to increase protein intake for a client with taste changes?
Encourage cheese and sandwiches. Explanation: The nurse encourages the clients with taste changes to eat cheese and sandwiches. The nurse advises the client to drink protein beverages.
What intervention should the nurse provide to reduce the incidence of renal damage when a patient is taking a chemotherapy regimen?
Encourage fluid intake to dilute the urine. Explanation: The nurse should ensure adequate fluid hydration before, during, and after drug administration and assess intake and output. Adequate fluid volume dilutes drug levels, which can help prevent renal damage.
What does the nurse understand is the rationale for administering allopurinol for a patient receiving chemotherapy?
It lowers serum and uric acid levels. Explanation: Adequate hydration, diuresis, alkalinization of the acid crystals, and administration of allopurinol (Zyloprim) may be used to prevent renal toxicity.
A decrease in circulating white blood cells (WBC) is referred to as which of the following?
Leukopenia Explanation: A decrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count (ANC).
Cancer has many characteristics. What is one of the most discouraging characteristics of cancer?
Metastasis Explanation: Metastasis is one of cancer's most discouraging characteristics because even one malignant cell can give rise to a metastatic lesion in a distant part of the body. Not all cancerous tumors are large in size. Carcinogenesis is the process of malignant transformation and it is not a characteristic of cancer. Cancer grows rapidly, not slowly.
A nurse is teaching a community class about how to decrease the risk of cancer. Which food should the nurse recommend?
Oranges Explanation: A diet high in vitamin C and citrus may help reduce the risk of certain cancers, such as stomach and esophageal cancers. Hot dogs and smoked and cured foods are high in nitrates, which may be linked to esophageal and gastric cancers. Steak is a high-fat food that may increase the risk of breast, colon, and prostate cancers. (less)
You are a clinic nurse. One of your clients has found she is at high risk for breast cancer. She asks you what can be done to reduce her risk. What is a means of reducing the risk for breast cancer?
Prophylactic surgery Explanation: Prophylactic or preventive surgery may be done if the client is at considerable risk for cancer. Palliative surgery is done when no curative treatment is available. Curative surgery is performed to cure the disease process.
When the client complains of increased fatigue following radiotherapy, the nurse knows this is most likely to be related to which factor?
Radiation can result in myelosuppression. Explanation: Fatigue results from anemia associated with myelo suppression and decreased RBC production. The spreading of cancer can cause many symptoms dependent on location and type of cancer but not a significant factor to support fatigue with radiotherapy. The production of healthy cells can increase metabolic rate, but death of cancer cells does not support fatigue in this case. Fighting infection can cause fatigue, but there is no evidence provided to support presence of infection in this client.
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication?
Serum potassium level of 2.6 mEq/L Explanation: Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include a serum potassium level below 3.5 mEq/L, decreased urine output (less than 40 ml/hour), and abnormally low blood pressure. Urine output of 400 ml in 8 hours, serum sodium level of 142 mEq/L, and a blood pressure of 120/64 to 130/72 mm Hg aren't abnormal findings.
What should the nurse tell a female client who is about to begin chemotherapy and anxious about losing her hair?
She should consider getting a wig or cap before she loses her hair. Explanation: If hair loss is anticipated, purchase a wig, cap, or scarf before therapy begins. Alopecia develops because chemotherapy affects rapidly growing cells of the hair follicles. Hair usually begins to grow again within 4 to 6 months after therapy. Clients should know that new growth may have a slightly different color and textures
A nurse is administering a chemotherapeutic medication to a client, who reports generalized itching and then chest tightness and shortness of breath. The nurse immediately
Stops the chemotherapeutic infusion Explanation: The client may be experiencing a type I hypersensitivity reaction, which may progress to systemic anaphylaxis. The most immediate action of the nurse is to discontinue the medication followed by initiating emergency protocols
The nurse is invited to present a teaching program to parents of school-age children. Which topic would be of greatest value for decreasing cancer risks?
Sun safety and use of sunscreen Explanation: Pool and water safety as well as infection prevention are important teaching topics but will not decrease cancer risk. While performing breast and testicular self-exams may identify cancers in the early stage, this teaching is not usually initiated in school-age children. Severe sunburns that occur in young children can place the child at risk for skin cancers later in life. Because children spend much time out of doors, the use of sunscreen and protective clothing/hats can protect the skin and decrease the risk.
A nurse is administering daunorubicin (DaunoXome) to a patient with lung cancer. Which situation requires immediate intervention?
The I.V. site is red and swollen. Explanation: A red, swollen I.V. site indicates possible infiltration. Daunorubicin is a vesicant chemotherapeutic agent and can be very damaging to tissue if it infiltrates. The nurse should immediately stop the medication, apply ice to the site, and notify the physician. Although nausea, WBC count of 1,000/mm3, and shivering require interventions, these findings aren't a high priority at this time.
The physician is attending to a 72-year-old patient with a malignant brain tumor. The physician recommends immediate radiation therapy. Which of the following is a reason for the physician's recommendation?
To prevent the formation of new cancer cells Explanation: Radiation therapy helps in preventing cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present; also, it can be used prophylactically to prevent spread. Biopsy is used for analyzing the lymph nodes or for destroying the surrounding tissues around the tumor. (less)
Your client is receiving radiation therapy. The client asks you about oral hygiene. What advice regarding oral hygiene should you offer?
Use a soft toothbrush and avoid an electronic toothbrush. Explanation: The nurse advises the client undergoing radiation therapy to use a soft toothbrush and avoid electronic toothbrushes to avoid skin lacerations. Gargling after each meal, flossing before going to bed, and treating cavities immediately are general oral hygiene instructions. (less)
The nurse is evaluating the client's risk for cancer and recommends changes when the client states she
eats red meat such as steaks or hamburgers every day Explanation: Dietary substances such as nitrate-containing, nitrite-containing, and red meats appear to increase the risk of cancer. Exercising 30 minutes on 5 days or more is recommended for adults. Measures are taken to protect those people who work around radiation. It is OK to drink 1 glass of wine per day.
A decrease in circulating white blood cells is
leukopenia. Explanation: A decrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low ANC.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention?
Administering metoclopramide and dexamethasone as ordered Explanation: The nurse should assign highest priority to administering an antiemetic, such as metoclopramide, and an anti-inflammatory agent, such as dexamethasone, because it may reduce the severity of chemotherapy-induced nausea and vomiting. This intervention, in turn, helps prevent dehydration, a common complication of chemotherapy.
Which of the following is a sign or symptoms of septic shock?
Altered mental status Explanation: Signs of septic shock include altered mental status, cool and clammy skin, decreased urine output, and hypotension.
Which type of vaccine uses the patient's own cancer cells that are prepared for injection back into the patient?
Autologous Explanation: Autologous vaccines are made from the patient's own cancer cells, which are obtained during diagnostic biopsy or surgery. Prophylactic vaccines, such as polio vaccine, are given to prevent people from developing a disease. Therapeutic vaccines are given to kill existing cancer cells and to provide long-lasting immunity against further cancer development. Allogeneic vaccines are made from cancer cells that are obtained from other people who have a specific type of cancer.
The nurse at the clinic explains to the patient that the surgeon will be removing a mole on the patient's back that has the potential to develop into cancer. The nurse informs the patient that this is what type of procedure?
Prophylactic Explanation: Prophylactic surgery involves removing nonvital tissues or organs that are at increased risk of developing cancer. When surgical cure is not possible, the goals of surgical interventions are to relieve symptoms, make the patient as comfortable as possible, and promote quality of life as defined by the patient and family. Palliative surgery and other interventions are performed in an attempt to relieve complications of cancer, such as ulceration, obstruction, hemorrhage, pain, and malignant effusions (Table 15-6). Reconstructive surgery may follow curative or radical surgery in an attempt to improve function or obtain a more desirable cosmetic effect. Diagnostic surgery, or biopsy, is performed to obtain a tissue sample for histologic analysis of cells suspected to be malignant.
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?
Stage 3 pressure ulcer on the left heel Explanation: A stage 3 pressure ulcer is a break in the skin's protective barrier, which could lead to infection in a client who is receiving chemotherapy. A client who is malnourished is at a greater risk for infection.
A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed?
"I guess the doctor could not remove the entire tumor." Explanation: Debulking is a reference made when a tumor cannot be completely removed, often due to its extension far into healthy tissue. Without complete removal, this is not a cure and, the cancer cells will continue to replicate and require adjuvant therapies to prevent further invasion. The physician, not the nurse, will need to clarify the details of the surgery.
Which statement by a client undergoing external radiation therapy indicates the need for further teaching?
"I'm worried I'll expose my family members to radiation." Explanation: The client undergoing external radiation therapy requires further teaching when he voices a concern that he might expose his family to radiation. Internal radiation, not external radiation, poses a risk to the client's family. The client requires no further teaching if he states that he should wash his skin with mild soap and water, wear protective clothing when outside, and avoid using a heating pad.
The nurse is caring for a client who is scheduled for chemotherapy. Which is the best statement the nurse can make about the client experiencing chemotherapy-induced alopecia?
"The hair loss is temporary." Explanation: Alopecia associated with chemotherapy is usually temporary and will return after the therapy is completed. New hair growth may return unchanged, but there is no guarantee and color, texture, and quality of hair may be changed. There is no correlation between chemotherapy and delay in greying of hair. Use of wigs, scarves, and head coverings can be used by clients at any time during treatment plan.
Which of the following does a nurse thoroughly evaluate before a bone marrow transplant (BMT) procedure?
Blood studies Explanation: Before the BMT procedure, the nurse thoroughly evaluates the patient's physical condition; organ function; nutritional status; complete blood studies, including assessment for past antigen exposure, such as HIV, hepatitis, or cytomegalovirus; and psychosocial status. Before a BMT procedure, the nurse need not evaluate patient's family, drug, or allergy history.
Which of the following does a nurse thoroughly evaluate before a hematopoietic stem cell transplant (HSCT) procedure?
Blood studies Explanation: Before the HSCT procedure, the nurse thoroughly evaluates the patient's physical condition; organ function; nutritional status; complete blood studies, including assessment for past antigen exposure, such as HIV, hepatitis, or cytomegalovirus; and psychosocial status. Before an HSCT procedure, the nurse need not evaluate patient's family, drug, or allergy history. (less)
You are the nurse caring for a client with cancer. The client complains of pain and nausea. When assessed, you note that the client appears fearful. What other factor must you consider when a client with cancer indicates signs of pain, nausea, and fear?
Fatigue Explanation: Clients with cancer experience fatigue, which is a side effect of cancer treatments that rest fails to relieve. The nurse must assess the client for other stressors that contribute to fatigue such as pain, nausea, fear, and lack of adequate support. The nurse works with other healthcare team members to treat the client's fatigue. The above indications do not contribute to infections, ulcerations, or high cholesterol levels.
The nurse is working with a patient who has had an allohematopoietic stem cell transplant (HSCT) and notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the patient has symptoms of which of the following?
Graft-versus-host disease Explanation: Graft-versus-host disease is a major cause of morbidity and mortality in patients who have had allogeneic transplant. Clinical manifestation of the disease include diffuse rash that progresses to blistering and desquamation, and mucosal inflammation of the eyes and the entire GI tract with subsequent diarrhea, abdominal pain, and hepatomegaly
A client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer?
Indigestion Explanation: Indigestion is one of the seven warning signs of cancer. The other six are a change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, a thickening or lump in the breast or elsewhere, an obvious change in a wart or mole, and a nagging cough or hoarseness. Persistent nausea may signal stomach cancer but isn't one of the seven major warning signs. Rash and chronic ache or pain seldom indicate cancer. (less)
A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents?
Wear disposable gloves and protective clothing. Explanation: A nurse must wear disposable gloves and protective clothing to prevent skin contact with chemotherapeutic agents. The nurse shouldn't recap or break needles. The nurse should use a sterile gauze pad when priming I.V. tubing, connecting and disconnecting tubing, inserting syringes into vials, breaking glass ampules, or other procedures in which chemotherapeutic agents are being handled. Contaminated needles, syringes, I.V. tubes, and other equipment must be disposed of in a leak-proof, puncture-resistant container
Which of the following would be inconsistent as a common side effect of chemotherapy?
Weight gain Common side effects seen with chemotherapy include myelosuppression (is the decrease in production of cells responsible for providing immunity (leukocytes), carrying oxygen (erythrocytes), and/or those responsible for normal blood clotting (thrombocytes).), alopecia, nausea and vomiting, anorexia, and fatigue.
