Part Two: Scientific Basis for Practice

13. Which one of the following mutations is associated with a hereditary risk for developing lobular breast cancer? A. MUTYH B. BRCA2 C. CDH1 D. PMS2

13. Answer C Rationale: Mutations in the CDH1 gene are associated with a 45% lifetime risk of developing lobular breast cancer, as well as an increased risk for developing diffuse gastric cancer. MUTYH mutations are associated with an autosomal recessive condition that places the individual at increased risk for colon polyposis. BRCA 2 mutations are associated with an increased risk for developing breast cancer, but not necessarily lobular breast cancer. PMS2 mutations are part of Lynch syndrome. Individuals with Lynch syndrome are at particularly high risk for developing colon, uterine, ovarian, and other gastrointestinal cancers.

6. The virus that is most commonly associated with hepatocellular cancer is which one of the following? A. Hepatitis C virus B. Influenza C. Human papillomavirus infection D. Human immunodeficiency virus

6. Answer: A Rationale: Risk factors for hepatocellular cancer include hepatitis C virus (HCV), hepatitis B virus (HBV), cirrhosis, diabetes, and obesity. Influenza is not a known risk factor for malignancy. Human papillomavirus infection (HPV) and human immunodeficiency virus (HIV) are risk factors for anal cancer.

6. F.R. is a 60-year-old male patient, who has been diagnosed with metastatic melanoma. During an office visit, F.R. asks the nurse, "What will happen to me next?" In answering his question, his nurse anticipates what his standard treatment will include. In her explanation, she includes which one of the following treatments? A. isolated limb perfusion B. immunotherapy C. cranial radiation therapy D. photodynamic therapy

6. Answer: B Rationale: Immunotherapy is the correct answer. Immunotherapy is considered the standard treatment for metastatic melanoma. Immunotherapy may consist of anti PD-1 monotherapy with pembrolizumab, or nivolumab or combination anti-CTLA-4anti-PD-1 with ipilimumab and nivolumab. The other options are not part of standard therapy for metastatic melanoma. Isolated limb perfusion may be used in certain clinical situations, and cranial radiation therapy may be used palliatively for patients with brain metastases.

15. Histologic characteristics of breast cancer are often determined by the Bloom-Richardson system. Which statement correctly reflects this histologic classification? A. Grade 1 - low grade and poorly differentiated B. Grade 1 - low grade and well differentiated C. Grade 1 - high grade and well differentiated D. Grade 1 - high grade and poorly differentiated

Answer B Rationale: In the Bloom-Richardson system or Nottingham grading system, Grade 1 reflects a low grade or well-differentiated breast cancer. Grade 2 represents an intermediate grade and moderately differentiated breast cancer. Grade 3 represents a high grade and poorly differentiated breast cancer.

9. Which one of the following is the most abundant granulocyte? A. Neutrophils B. Basophils C. Eosinophils D. Macrophages

Answer: A Granulocytes have granules in cytoplasm with enzymes that aid in digestion of foreign particles (phagocytosis) and cause inflammation. Neutrophils are the most abundant granulocytes, but they only live about 6 hours. Neutrophils cause inflammatory response due to engulfing and destroying foreign particles and debris. Basophils have IgE receptors that are involved in allergic responses and cause release of histamine and prostaglandins. Eosinophils attack parasites and secrete cytokines that cause inflammation during allergic responses. Macrophages rapidly recognize, ingest, and kill microbes; macrophages are not granulocytes.

8. Which one of the following statements about basel cell carcinoma is true? A. Major risk factor is exposure to UVR, especially intermittent exposure early in life B. Most commonly presents as an erythematous or violaceous, tender, dome-shaped nodule on sun-exposed areas on the head or neck of an elderly white male C. Typically, these are slow growing, however, those arising in in non-sun-exposed sites (i.e., lips, genitalia, perianal areas) are more aggressive with a higher risk of metastases D. Most lesions are < 2 cm in diameter at the time of diagnosis; rapid growth is common

Answer: A Rationale: A major risk factor in basal cell carcinoma (BCC) is UVR, specifically intermittent exposure early in life. Characteristics of Merkel cell carcinoma (MCC) are that MCCs most commonly present as erythematous or violaceous, tender, dome-shaped nodules on sun-exposed areas on the head or neck of an elderly white male. Most MCC lesions are < 2 cm in diameter at the time of diagnosis, and rapid growth is common. Cutaneous squamous cell carcinoma (cuSCC) are typically slow growing; however, those arising in non-sun-exposed sites (i.e., lips, genitalia, perianal areas) are more aggressive with a higher risk of metastases.

5. Which of the following statements explains the derivation of a cancerous tumor? A. Genetic mutations in genes that control cell growth and proliferation are commonly associated with the development of cancer. B. Proto-oncogenes are frequently associated with the proliferation and development of malignancies. C. Passenger mutations are essential to cancers caused by driver mutations. D. Mutations in a DNA repair gene are not associated with environmental carcinogens or inheritance.

Answer: A Rationale: A malignant tumor is derived from genetic instability and genetic mutations in genes that control cell growth and proliferation. B is incorrect as proto-oncogenes are normal genes essential for normal cell growth and proliferation. Mutations occurring in proto-oncogenes convert to oncogene activation to cause uncontrolled cell division. C is incorrect because driver mutations offer a selective growth advantage to cancerous cells, while passenger mutations do not. D is incorrect as mutations in DNA repair genes may be inherited from a parent or acquired over time due to aging or impact of carcinogens from the environment.

8. Typical signs and symptoms of recurrent ovarian cancer include which one of the following? A. rising CA125 tumor marker B. weight gain C. increased appetite D. vaginal discharge or bleeding

Answer: A Rationale: A rising CA125 is a biochemical sign of relapse or recurrence. Possible signs of ovarian cancer recurrence include abdominal bloating, bowel/bladder changes, weight loss, early satiety, nausea, vomiting, and ascites. Vaginal discharge and bleeding is not a common symptom associated with ovarian cancer.

2. Individuals from the general population who are enrolled in a clinical trial study to evaluate a new technique for early detection of skin cancer are in which type of the following clinical trials? A. Screening B. Diagnostic C. Quality of life D. Prevention

Answer: A Rationale: A screening trial evaluates the effectiveness of new techniques for early detection of cancer in the general population. A diagnostic trial evaluates tests or procedures that may better identify cancer in symptomatic individuals. A quality of life trial explores pharmacologic or non-pharmacologic therapies to minimize cancer related toxicities. A prevention trial evaluates the safety and efficacy of various risk reduction strategies such as chemoprevention or actions such as increasing fruit and vegetable intake, adding exercise, avoiding tobacco, or limiting alcohol use.

12. According to the American Cancer Society and the National Cancer Institute, which one of the following is a risk factor for developing a soft tissue cancer? A. Exposure to radiation B. Damaged immune system C. Food allergies D. Exposure to certain viruses

Answer: A Rationale: According to the American Cancer Society and the National Cancer Institute, exposure to radiation is an identified risk factor for developing cancer of the soft tissue. A damaged immune system is not a risk factor, but a damaged lymph system is an example of a risk factor. Food allergies and exposure to viruses have not been identified as risk factors in developing soft tissue cancers. However, exposure to certain types of chemicals and particular types of family cancer syndromes are examples of risk factors that have been identified.

10. Which statement is accurate regarding the epidemiology of leukemia? A. The most common type of leukemia in children is acute lymphocytic leukemia. B. The most common type of leukemia in children is chronic myelogenous leukemia. C. The most common type of leukemia in children is chronic lymphocytic leukemia. D. The most common type of leukemia in adults is acute lymphocytic leukemia.

Answer: A Rationale: Acute lymphocytic leukemia (ALL) is the most common form of leukemia among children and adolescents representing 20% of all cancers among persons less than 20 years representing 3000 new cases annually. The risk declines after 5 years of age until the middle twenties and then rises again after the age of 50. In chronic myelogenous leukemia (CML), the average age at diagnosis is greater than 60 years with half of the total cases being over the age of 65. Chronic lymphocytic leukemia (CLL) is the most frequent form of leukemia and originates from mature B lymphocytes. The median age at diagnosis is 60 years, and less than 15% are diagnosed under the age of 50. The lifetime risk of CLL is 1 in 175 and is most commonly diagnosed at 70 years of age. CLL accounts for 25% of all leukemias and is more frequently seen in Caucasians compared with Asians, as well as Hispanics.

7. Immediate post-operative care of patients with surgical grafting done during head and neck cancer surgery would include assessment of which one of the following? A. perfusion of blood supply to the graft site B. range of motion in the shoulders C. need for debridement necrotic tissue D. blood clots and need for lavage

Answer: A Rationale: After a patient undergoes head and neck surgery that includes skin or muscle grafts to cover the removed tumor site, postoperative wound care assessment is every 3 to 4 hours, noting color (pink versus cyanotic), temperature, and capillary refill after blanching of the skin and muscle. Flap perfusion and viability is maintained by avoiding excess pressure to the flap; the wound is assessed for infection and fistula formation. Nursing assessment of surgical grafts does not include range of motion, necrotic tissue removal, or regular lavage.

16. Which of the following diseases does not increase the risk for a primary brain tumor? A. Huntington disease B. Neurofibromatosis type 1 C. Li-Fraumeni syndrome D. von Hippel-Lindau disease

Answer: A Rationale: All the listed are genetic diseases, but the only one that is not associated with risk of developing brain cancer is Huntington's disease. Neurofibromatosis type 1 is associated with malignant peripheral nerve sheath tumors, optic gliomas, meningiomas, hamartomatous intestinal polyps other gliomas, and leukemias. Li Fraumeni syndrome is associated with soft tissue sarcoma, osteosarcoma, pre-menopausal breast cancer, brain tumors, adrenocortical carcinoma (ACC), and leukemias. Von Hippel Lindau disease is associated with renal cancers, pancreatic neuroendocrine tumors, hemangioblastomas, and pheochromocytomas.

3. K.T. is a 29-year old female patient, who has been newly diagnosed with breast cancer. K.T. has asked her oncology nurse why the oncologist would require the result of the biomarker test to determine the treatment plan. Which of the teach-back responses indicates that the patient did not fully understand her oncology nurse's explanation? A. The results will tell us if I need surgery. B. The results can predict if the treatment will work for me. C. My doctor will use the results to find out if I will need chemotherapy after surgery. D. The results can be used to measure how aggressive my cancer is.

Answer: A Rationale: Biomarkers can determine disease severity and outcomes and aids in treatment planning. A biomarker is a molecule found in blood, tissues, or other body fluids that signals the presence of a condition or disease; can be used to evaluate response to treatment. Predictive biomarkers provide information on the effect of a therapeutic intervention. A prognostic biomarker biomarker provides information about the patient's overall cancer outcome, regardless of therapy. Biomarkers are not generally used to determine if a patient is a candidate for surgery. A germline mutation may suggest the need for risk reducing surgery.

12. Chronic myelogenous leukemia (CML) is a clonal disorder that originates from which one of the following? A. Philadelphia chromosome B. ataxia telangiectasia mutated (ATM) gene C. germline tp53 mutated gene D. trisomy 21

Answer: A Rationale: Chronic myelogenous leukemia (CML) is a clonal disorder that originates from the Philadelphia chromosome translocation of the BCR-ABL oncogene. The translocation between chromosome 9 and 22 fuses together causing tyrosine kinase activity, which results in initiation of leukemia (Philadelphia chromosome). There are three phases of this disorder, which include chronic, accelerated, and blast crisis phase. Inherited mutations in the ATM (Ataxia Telangiesctasia mutated) gene are associated with increased risk of certain cancers. People who inherit a mutated copy of ATM from one parent are at increased risk of female breast cancer (up to 52% lifetime risk), and possibly pancreatic, prostate, and other cancers. Persons who inherit two copies of the ATM gene develop ataxia-telangiectasia syndrome or Louis-Bar syndrome, which is a rare, neurodegenerative, autosomal recessive disease, which causes severe disability. Persons with inherited (germline) tp53 mutations are at risk for breast, lung, colon, gynecologic, sarcomas, and many other cancers and have a condition known as Li Fraumeni syndrome. Trisomy 21, also known as Down syndrome is a human chromosomal disorder caused by having three copies (trisomy) of chromosome 21.

3. A new oncology nurse is reviewing a patient's medical record and requests help in understanding the process of carcinogenesis. A seasoned nurse explains that the process is due to which one of the following? A. clonal evolution B. convergent evolution C. coevolution D. perseverance

Answer: A Rationale: Clonal evolution describes the process of cells within a tumor accumulating genetic changes over time that are different from once cell to the next, A tumor may be varied and consist of cells that rose from the same mother cell that are genotypically different from one another, and arise from the survival of the fittest collection of cancer cells. Convergent evolution and changes and coevolution are two of the six important patterns of macroevolution, which are not involved in the development of carcinogenesis. Perseverance is a term to indicate steadfastness and does not relate to the process of carcinogenesis

4. Attending a local health fair, an oncology nurse is staffing a booth promoting cancer prevention. A man comes to her booth and questions whether or not he should have screening for lung cancer. She instructs him that the guidelines for screening include which one of the following? A. ≥30 pack-years B. age 70 years or greater C. use of inhaled marijuana D. vaporized cigarette use

Answer: A Rationale: Current screening guidelines for lung cancer screening are for current or former smokers (> 30 pack-years or quit < 15 years), asymptomatic, age 55 to 74, to have annual screening with low-dose chest CT. The nurse working the local health fair, then, should have provided instructions for answer A. The use of inhaled marijuana and the use of electronic cigarettes have not been established as risk factors in the development of lung cancer.

11. Which mutation-identifying technique will determine the number of mutations in chromosomes? A. cytogenetics B. Sanger sequencing C. genome-wide association studies (GWAS) D. microarray

Answer: A Rationale: Cytogenetic reports include modal number of chromosomes, sex chromosome designation; abnormality abbreviation - first chromosome separated with a semicolon from the second chromosome, then the arm and band number B is incorrect as this detects sequence changes in regions being analyzed. Sanger sequencing is a form of gene sequencing that determines the sequence of a gene being tested and detects sequence changes in regions being analyzed. A limitation of this testing is that it may miss mutations outside the coding region or mutations that are large genomic rearrangements or large deletions The GWAS sequencing reviews for changes with specific disease (cancer type) versus people without the cancer. D is incorrect as microarrays are used for mutation detection and gene expression.

6. Cytokines function to do which one of the following? A. assist with cell signaling during immune responses B. recognize, ingest, and kill microbes C. produce antibodies against antigens after exposure D. supply tissue nourishment, improve oxygenation, and modulate blood viscosity

Answer: A Rationale: Cytokines are proteins that assist in communication between cells of the immune system to aid in rapid response. Macrophages are immune cells of the innate immune system that release cytokines to produce inflammatory response and present antigens to T cells. Plasma cells are differentiated B cells, which produce one specific antibody against a specific antigen as part of the humoral immune response. Erythrocytes or red blood cells develop in the bone marrow and transport oxygen to the body's tissues.

13. Which one of the following is a modifiable risk for stomach cancer? A. Diet high in salted and smoked foods B. Gastric polyps C. Previous gastric surgery D. Family history of the disease

Answer: A Rationale: Diets which are high in salted and smoked foods, and low in fruit and vegetable consumption is known as a modifiable risk factor for stomach cancer. Gastric polyps are considered a nonmodifiable risk, as is previous gastric surgery, and a family history of the disease. Other modifiable risks include alcohol intake of more than four drinks per day, smoking, and gastric ulcers. Obesity is also associated with gastric cardia cancer.

9. Which one of the following is the most common and severe symptom reported by a patient with a primary brain tumor? A. fatigue B. headache C. seizures D. constipation

Answer: A Rationale: Each of these symptoms may be prevalent in persons with brain cancer, however not with the same frequency or severity as fatigue.

3. Which one of the following is a characteristic of an expanded access protocol? A. An investigational drug is used outside of a designated clinical trial. B. Provides a means to use a therapy off label. C. Patient must have early-stage cancer. D. Requires United States Food and Drug Administration approval within 72 hours of use.

Answer: A Rationale: Expanded access provides a means for patients and their physicians to use an investigational drug outside of a designated clinical trial. Off label use of a drug is not a characteristic of expanded access. Expanded access is restricted to patients with a serious condition or disease who no longer have satisfactory medical options available. In compassionate use, not expanded access, approval from FDA may be obtained within 24 hours in emergency situations.

5. Oncogenic human papillomavirus (HPV) infection and smoking have been associated with an increased risk of developing cervical cancer, vaginal cancer, and vulvar cancer. Which one of the following additional risk factors would be correctly considered for the patients below? A. An additional risk factor would be diethylstilbestrol use by the mother of a patient diagnosed with vaginal cancer. B. An additional risk factor would be breast cancer in a first degree relative of a patient diagnosed with cervical cancer. C. An additional risk factor would be asbestos exposure in the mother of a patient diagnosed with vulvar cancer. D. An additional risk factor would be personal use of hormone replacement therapy by a patient diagnosed with vulvar cancer.

Answer: A Rationale: Exposure to DES in utero (DES used by the mother, while pregnant) can increase the risk of congenital abnormalities and vaginal cancer in offspring. Breast cancer in a first-degree relative and use of HRT are not known risk factors associated with vaginal, vulvar, or cervical cancer. Asbestos exposure in a parent has not been shown to increase vaginal, vulvar, or cervical cancer risk in offspring.

Chapter 18 Leukemia 1. A risk factor for developing acute lymphoblastic leukemia is which one of the following? A. exposure to Epstein-Barr virus (EBV) B. being of African descent C. being of Asian descent D. having had a diagnosis of measles as a child

Answer: A Rationale: Exposure to certain viruses, such as EBV and HTLV-1, is a risk factor for developing ALL. Being of Hispanic descent, not African or Asian, is a risk factor for developing ALLH. Having a genetic condition such as Down syndrome, Li-Fraumeni syndrome, Ataxia telangiectasia, Klinefelter syndrome, and Fanconi Anemia is a risk factor for developing ALL. A diagnosis of measles is not a known risk factor.

10. Which one of the following is an example of adjuvant chemotherapy therapy for colon cancer? A. FOLFOX B. Carboplatin/paclitaxel C. FOLFIRI D. Cetuximab

Answer: A Rationale: FOLFOX is a chemotherapy regimen used for colon cancer in both the adjuvant and metastatic settings. CAPEOX, capecitabine, and 5-FU/leucovorin are also often used in the adjuvant setting. Carboplatin/paclitaxel is not a chemotherapy regimen used for colon cancer, but is considered a common chemotherapy regimen used in ovarian and lung cancers. Cetuximab and FOLFIRI are used in the metastatic colorectal cancer setting.

8. H.M. is a 47-year-old female who has been newly diagnosed with stage IIa lung cancer. After consultation with her oncology health care team, she has decided against having surgery. The oncology nurse caring for the patient knows that the next best treatment for this patient would be which one of the following? A. stereotactic ablative radiotherapy (SABR) B. oral chemotherapy C. low-energy radiation D. immunotherapy

Answer: A Rationale: For early-stage NSCLC (stage I or IIa disease), stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR) is recommended for the patient who is not a surgical candidate or who refuses therapy. Oral chemotherapy is not an indication for treatment for this stage lung cancer. Low energy radiation does not penetrate deeply enough and is used mainly to treat skin cancers, and not NSCLC. Immunotherapy is often used for patients who have failed previous therapies.

7. K.T., a 29-year old female patient with breast cancer, has requested information on genetic and molecular testing. Her oncology nurse knows that her patient will need more information when she is heard saying: A. Please expedite the results. I need them in 2 days for my second opinion. B. I understand that my results may have implications to the rest of my family. C. I will need to inquire if my health insurance will cover the costs related to genetic and molecular testing. D. There are known risks to my privacy and confidentiality.

Answer: A Rationale: Genetic testing results may take up to 8 weeks and cause waiting-related patient anxiety when treatment is dependent on results. Germline genetic testing has implications for both the patient and family members. It can be expensive and insurance preauthorization is often required. Informed consent issues include how privacy will be maintained and use of the specimen after testing is completed

2. J.L. is a 63-year-old female patient who has recently been diagnosed with kidney cancer. She is concerned and confused because kidney cancer does not run in her family, and she asks her nurse for an explanation. Her nurse explains that two factors associated with increased risk include which one of the following? A. having a history of non-Hodgkin lymphoma and being overweight B. being of Asian descent and having a history of kidney stones C. consuming processed meats and sedentary occupation D. having a tall stature and being underweight

Answer: A Rationale: Having a history of non-Hodgkin lymphoma and being overweight is the correct answer. The other choices are not correct because they are not known risk factors for kidney cancer, which include lifestyle risk factors such as tobacco use, obesity, and occupational exposure to petroleum products or heavy metals. Dietary risk factors include diets high in fats and protein. Finally, a history of non-Hodgkin lymphoma or sickle cell disease is also considered a risk factor.

7. S.W. is a 60-year-old female patient with a diagnosis of chronic lymphocytic leukemia. Upon review of the patient's medication list, her nurse notes that this patient is taking ibrutinib for her diagnosis. The nurse would expect for her patient to have which one of the following markers? A. 17p deletion B. TP53 mutation C. CD20 antigen D. CD52 antigen

Answer: A Rationale: Ibrutinib is used for patients with 17p deletion. There is no known targeted therapy for TP53 mutation. Rituxmiab is used for patients with CD20 antigen. Alemtuzumab is used for patients with CD52 antigen.

2. The concept of immune surveillance occurs: A. when innate and adaptive immunity destroy clinically unmeasurable tumors B. when a rare cancer clone requires resistance to innate immunity but is stabilized by the adaptive immune system C. when tumors enter the equilibrium phase of the proposed tumor suppression mechanism D. as a result of receiving multiple, sequential chemotherapeutic agents

Answer: A Rationale: Innate and adaptive immunity is the elimination phase of extrinsic tumor suppression mechanism, where the host's immune system responds to microscopic invasion by destroying circulating tumor cells. This is a homeostatic process ongoing in host's with an intact immune system. B is an example of the equilibrium phase of tumor suppression where the first line of defense with natural barriers and inflammatory response have been overcome. Humoral and cell-mediated immunity mechanisms are now holding tumor growth in check. C is incorrect as the equilibrium phase occurs once resistant tumor clones escape immune surveillance and innate immunity has been overcome. D is incorrect as the mechanism of action with chemotherapeutic agents is cell death through cytotoxic cellular processes that inhibit mitosis. Immunotherapy agents function to increase immune surveillance through modification of the adaptive immune system.

2. A risk factor for head and neck cancer includes which one of the following? A. Human papillomavirus (HPV) B. diabetes C. menopause D. dental implants

Answer: A Rationale: Known risk factors for head and neck cancer include the following: tobacco use, excessive alcohol, indigestion, the human papillomavirus (HPV), gastroesophageal reflux, history of neck radiation, and environmental exposure (wood, dust, asbestos). In men, 81% of all HPV associated cancers are oropharynx cancers. In women, 15% of all HPV-associated cancers are oropharynx cancers. Diabetes, menopause, and dental implants are not known risk factors.

14. Which one of the following is true about Luminal A tumors? A. Luminal A tumors have the highest levels of ER expression: ER positive and/or PR-positive B. Luminal A tumors tend to be high grade C. Luminal A tumors seldom respond to endocrine therapy D. Luminal A tumors have a poor prognosis

Answer: A Rationale: Luminal A tumors have the highest levels of ER expression: ER-positive and/or PR-positive, these tumors tend to be low grade, are most likely to respond to endocrine therapy, are responsive to chemotherapy, and have a favorable prognosis. Luminal B tumors are typically ER-positive, PR- negative, HER2-positive, and may have an unfavorable subset with aggressive behavior that can be tamoxifen resistant. Basal tumors are negative for ER, PR, and HER2 (triple-negative). They tend to be high grade and often have a poor prognosis; therefore, these tumors will likely benefit from chemotherapy

3. Which one of the following patients should undergo genetic testing for mutation? A. A 60-year-old male with breast cancer. B. An 80-year-old female with grade 1, estrogen receptor (ER)-positive, progestogen receptor (PR)-positive breast cancer. C. A 55-year-old female with ductal carcinoma in situ (DCIS). D. A 60-year-old female who is post-menopausal with no family history.

Answer: A Rationale: Male breast cancer is an indication for referral for genetic evaluation. Women diagnosed with breast cancer at age 50 or under should be given consideration for genetic evaluation, as well as women age 60 and under with triple negative breast cancer. Answers B, C, and D reflect on women with average or older age of onset. These women would not be considered for referral for genetic evaluation unless there was a family history of breast, ovarian, melanoma, pancreatic, prostate, or colon cancer, or possibly a diagnosis of two primary breast cancers.

Chapter 12 Bone and Soft Tissue Cancers 1. Primary tumors that have been known to spread to the bone include which one of the following? A. prostate B. brain C. leukemia D. melanoma

Answer: A Rationale: Metastatic tumors spread to the bone from primary solid tumors. Common tumors include lung, breast, kidney, thyroid, and prostate cancers. Primary cancers that do not spread to the bone include brain cancer, leukemia, and melanoma.

2. Which one of the following is a risk factor for gastric cancer that is considered modifiable? A. Alcohol B. Family history C. Epstein-Barr virus D. Lynch syndrome

Answer: A Rationale: Modifiable risk factors are those within the control of the individual. For example, alcohol use is considered a modifiable risk factor. Individuals cannot control their family history nor can they control a history of genetic risk, such as Lynch syndrome. Exposure to the Epstein-Barr virus is also considered nonmodifiable.

6. The primary tumor that most frequently metastasizes to the brain is which one of the following? A. non-small cell lung cancer B. prostate cancer C. liver cancer D. colorectal cancer

Answer: A Rationale: Non-small cell lung cancer (NSCLC) accounts for 85% of lung cancer diagnoses and is also the most common primary tumor metastasizing to brain, with about 9% of patients with NSCLC developing brain metastases. Prostate cancer commonly metastasizes to the adrenal gland, bone, liver, and lung. Liver cancer is often the site of metastatic cancer. Colorectal cancer typically metastasizes to the liver, lung, and peritoneum.

8. The tumor type most frequently associated with leptomeningeal carcinomatosis originates from which one of the following? A. breast B. lung C. hematologic malignancies D. prostate

Answer: A Rationale: Of all tumor types, leptomeningeal carcinomatosis is more frequently associated with breast tumors (35%), followed by lung tumors (24%), and then hematologic malignancies (16%).

3. Adaptive immunity differs from innate immunity in that adaptive immunity: A. creates memory cells for a longer lived immune response B. uses humoral immunity through T-cell activation C. uses feedback inhibition mechanisms to control tissue damage due to inflammatory response D. uses nonspecific processes for immune defense

Answer: A Rationale: Only the adaptive immune system has memory. The innate immune system is a rapid cellular response to invasion of pathogens and/or tissue damage and does not rely on previous exposure to initiate an immune response. Humoral immunity uses antibodies produced by B lymphocytes, which respond to a specific antigen. Cell-mediated immunity uses T lymphocytes to active immune responses. Inflammatory response is controlled by the innate immune system, not adaptive immune system. Nonspecific processes for immune defense is related to innate immunity. The adaptive immune system uses processes to create antibodies and T lymphocyte activation to respond to specific antigens.

Chapter 19 Lung Cancer 1. An oncology nurse is caring for a patient with lung cancer who is exhibiting intrathoracic effects of his disease. The nurse is aware that the signs and symptoms of this disease include which one of the following? A. shoulder pain B. neuropathy in bilateral lower extremities C. hypomagnesia D. darkening of the skin

Answer: A Rationale: Pancoast syndrome can result when a superior sulcus, such as lung cancer, destroys lesions of the thoracic inlet and involves the brachial plexus and cervical sympathetic nerves, and is manifested by shoulder pain. Other intrathoracic effects include pleural effusions and superior vena cava syndrome. Lower extremity neuropathy and darkening of the skin are not intrathoracic effects of lung cancer. While hypomagnesia does not have an intrathoracic effect due to lung cancer, it can be associated with hypercalcemia, which is a known oncologic emergency seen in persons with lung cancer.

8. What percentage of pancreatic cancers are classified as adenocarcinomas? A. 95% B. 80% C. 25% D. 5%

Answer: A Rationale: Pancreatic adenocarcinoma is the most common form of pancreatic cancer. It accounts for almost 95% of cases and arises from the exocrine pancreas. Pancreatic neuroendocrine tumors are less common but tend to have a better prognosis.

4. Diagnostic tests reveal that a patient with limited renal function has developed a primary tumor in the kidney. The nurse should anticipate an order to prepare the patient for which one of the following treatments? A. Partial nephrectomy B. Cytoreductive nephrectomy C. Radiation therapy D. Chemotherapy

Answer: A Rationale: Partial nephrectomy is the preferred treatment whenever feasible, especially in patients with limited renal function, bilateral tumors, or a solitary kidney. Cytoreductive nephrectomy is a procedure that may be performed in patients with surgically resectable primary tumor and multiple metastatic sites prior to systemic therapy. Renal cell cancers are unresponsive to radiation therapy. Chemotherapy has not been shown to improve survival in kidney cancer.

Chapter 22 Neurologic System Cancers 1. An oncology nurse working with a pediatric patient population recognizes that which one of the following statements on pediatric brain and spinal cord tumors is true? Brain and spinal cord tumors are: A. the second most commonly diagnosed pediatric cancer. B. a rare diagnostic occurrence. C. the most frequently diagnosed pediatric cancer. D. most often diagnosed as benign tumors.

Answer: A Rationale: Pediatric tumors are most often malignant and are diagnosed more often than any other type of cancer in pediatrics except for leukemia.

2. A lab value commonly found in a patient diagnosed with acute lymphoblastic leukemia is which one of the following? A. the presence of peripheral blasts B. a normal blood urea nitrogen (BUN)/creatinine C. thrombophilia D. a normal prothrombin time (PT)/international normalized ratio (INR)

Answer: A Rationale: Peripheral blast cells are commonly found in a peripheral blood test for a patient newly diagnosed with ALL. Patients often have an elevated BUN/Creatinine at diagnosis. Patients usually have decreased platelet counts at diagnosis, not thrombophilia. Patients often have a change in PT/INR at diagnosis.

9. W. J. is a 56-year-old woman who has just had a mastectomy and was found to have had a positive lymph node. Which one of the following educational points should the nurse perform on the patient's first post-operative visit? A. Avoid injury and trauma to the affected arm B. Avoid upper extremity exercise C. Take temperature and report a temperature of more than 100°F D. Reduce sodium intake to less than 1800 mg daily

Answer: A Rationale: Prevention of lymphedema is far easier than treatment. Prevention measures include measuring the arm for increase in diameter postoperatively as compared to preoperatively. Other prevention measures include avoiding constriction to the arm from tourniquets and blood pressure cuffs as well as trauma or injuries that could lead to infection. Exercise should be supervised and gradually be added into the patient's daily routine. A temperature of greater than 100.5°F could be suggestive of a postoperative infection. Sodium intake has not been shown to impact lymphedema risk.

10. An oncology nurse caring for a patient with small-cell lung cancer is aware that, with this type of lung cancer, which one of the following is correct? A. brain radiation therapy is given to prevent metastasis B. there is greater than 5-year survival with response to treatment C. KRAS mutations are present, which guides treatment choice D. a lobectomy is often performed

Answer: A Rationale: Prophylactic cranial radiation therapy is indicated for individuals with complete response to chemotherapy or radiation therapy to reduce the risk of developing brain metastasis. The overall 5-year survival is poor at 5% to 10%. The KRAS oncogene is never mutated in small cell lung cancer but may be seen is non-small cell lung cancers. Surgery is rarely an option for the main treatment of small cell lung cancer, as the cancer has usually spread by the time it is found.

14. Mr. S. is a 60-year old man who has been diagnosed with bladder cancer. His nurse has told him of his options for bladder perseveration therapy, including describing what is considered to be the primary treatment modality being currently offered. After hearing the details, Mr. S. is reluctant to undergo the procedure and eventually declines. Which one of the following bladder preservation therapies did the patient most likely decline? A. Radical cystectomy B. External beam radiation therapy C. Trimodality therapy—transurethral resection (TUR) D. Radiation Therapy

Answer: A Rationale: Radical cystectomy is currently considered the primary treatment modality for bladder preservation but, due to the nature of the procedure, some patients either cannot tolerate the procedure or decline the treatment altogether. Alternatives to radical cystectomy include external beam radiation therapy, radiation therapy, and trimodality therapy—transurethral resection (TUR). Each of these treatments are considered as bladder preservation strategies, though the baseline therapy is currently radical cystectomy.

3. A 37-year-old female patient presents to the clinic with signs of Hodgkin's Lymphoma. The patient undergoes testing and her oncology nurse should anticipate seeing results confirming this diagnosis would include one of which of the following? A. reed-Steenberg cells B. bone marrow involvement C. extranodal involvement in distal sites D. metastases to the long bones

Answer: A Rationale: Reed-Sternberg cells on the patient's pathology examination are present with classic Hodgkin's lymphoma. Bone marrow involvement and lymphadenopathy with extranodal involvement are typically present in NHL. Metastases to the long bones are not diagnostic of Hodgkin's lymphoma.

9. A sarcoma of the blood vessels is characterized as which one of the following? A. Kaposi sarcoma B. liposarcoma C. rhabdomyosarcoma D. leiomyosarcoma

Answer: A Rationale: Sarcomas of the blood vessels include hemangiosarcoma and Kaposi Sarcoma. Liposarcoma is a sarcoma that starts in the fat cells. Rhabdomyosarcoma and leiomyosarcoma are sarcomas that originate in muscle cells.

9. Which one of the following is a type of chemotherapy used for cholangiocarcinoma? A. Gemcitabine B. Methotrexate C. Cytoxan D. Pembrolizumab

Answer: A Rationale: Systemic therapies used in adjuvant and advanced settings include fluoropyridamine-based or gemcitabine-based therapies. Pembrolizumab for patients with MSI-H/dMMR for second-line therapy and third- line therapy for patients PD-L1 positive. Cytoxan is not used in the treatment of colon cancer.

11. Which one of the following patients is most likely to develop breast cancer during their lifetime? A. T. K., who is a 27-year-old white woman. B. J.L, who is a 30-year-old Hispanic woman. C. D.C., who is a 25-year-old white male D. B.R, who is a 37-year-old African American woman.

Answer: A Rationale: T. K, a 27-year-old white woman, has a 1 in 8 chance that she will develop breast cancer in her lifetime. J.L., who is Hispanic, has a lower rate than the other races. Breast cancer is 100 more times likely in woman than in men, so D.C. has the smallest chances of the four choices. Finally, B.R., a 37-year-old African American woman, has a 1 in 10 chance of developing cancer. However, more African American women are diagnosed with breast cancer before the age of 45.

7. T.J. is a 22-year-old male who makes an appointment with the clinic after complaining of systemic symptoms that have gotten his clinician concerned about the possibility that he could be diagnosed with a lymphoma. Reading over his chart, the attending nurse would be likely suspicious of which one of the following systemic symptoms? A. Fever, weight loss, fatigue, and night sweats B. Pain in the chest area C. Swelling of the limbs D. Extreme thirst and frequent urination

Answer: A Rationale: T.J.'s systemic symptoms - fever, weight loss, fatigue, and night sweats - are considered "B" symptoms of lymphoma. The common clinical presentation of lymphoma is enlarged lymph nodes, spleen, and other immune tissue, with or without the systemic symptoms. Pain in the chest is not a symptom, but some patients do report pain in the nodal site when drinking (though the significance of such pain has not been established). Swelling of the limbs is not symptomatic, and extreme thirst and frequent urination could be signs of many conditions - from dehydration to diabetes - but is not a systemic symptom of lymphoma.

11. Primary central nervous system tumors are staged according to which one of the following? A. World Health Organization (WHO) classifications B. Tumor Node Metastasis (TNM) criteria C. National Comprehensive Cancer Network (NCCN) criteria D. American Joint Committee on Cancer (AJCC) classifications

Answer: A Rationale: The AJCC TNM classification system is not used to stage primary central nervous system tumors because two of three indicators are not applicable (there are no nodes and extracranial metastases extraordinarily rare). The World Health Organization (WHO) classification of a central nervous system tumor is universally applicable and prognostically valid. National Comprehensive Cancer Network (NCNN) does not provide staging/classification of disease criteria.

14. Which of the following groups are not included in the Genetic Non-Discrimination Act (GINA)? A. Native Americans B. African Americans C. Jewish Americans D. Southern Baptist Association

Answer: A Rationale: The Genetic Information Nondiscrimination Act (GINA), federal legislation enacted in 2008, applies to health insurance and employment discrimination based on genetic information. GINA does not apply to active duty military personnel, Veterans Administration, or Native American Health Service because the laws amended for GINA do not apply to these groups. Health insurance protections with GINA include protections against accessing an individual's genomic information, requirements for an individual to undergo a genetic or genomic test, and using genomic information against a person during medical underwriting. Employment protections include prohibiting employers from accessing an individual's genetic information, use of genomic information to deny employment, or collecting genomic information without consent. GINA does not supersede state legislation that provides for more extensive protections.

8. A tumor is formed from a single precursor cell with genetic alterations that undergoes clonal expansion. Clonal evolution is the process of cells within a tumor accumulating genetic changes over time that are different from one cell to the next. Thus, a tumor may be heterogeneous and consist of cells that arose from the same mother cell that are genotypically different from one another. In this model, which is the third phase in the process of cell mutation? A. Acquisition of cancer hallmarks B. Acquisition of genomic instability C. Initiating mutation D. Further genetic mutation

Answer: A Rationale: The acquisition of cancer hallmarks is classified as the third phase of the process of cell mutation. A tumor is formed from a single precursor cell with genetic alterations that undergoes clonal expansion. Clonal evolution is the process of cells within a tumor accumulating genetic changes over time that are different from one cell to the next. Initiating mutation is considered the first step in the process, acquisition of genetic instability is next, and, finally, the cell undergoes further genetic mutation.

Chapter 17 HIV-Related Cancers 1. The average time from human immunodeficiency virus (HIV) infection to symptomatic disease is best described as which one of the following? A. dependent on pre-existing health B. approximately 15 years C. dependent on age at time of exposure D. dependent on number of sexual partner

Answer: A Rationale: The average time from infection to active AIDS is approximately 10 years, not 15 years. It can be shorter in older adults and children. The average time from human immunodeficiency virus (HIV) infection to symptomatic disease depends on inoculation method, exposure, pre-existing health, and prompt initiation of treatment for antiretroviral disease, so A would be the best representative answer. The average time of infection is not dependent on the patient's age at time of exposure nor is it dependent on the number of sexual partners.

7. S.T. is a 70-year-old male, who has been recently diagnosed with multiple myeloma and is having a difficult time coming to terms with his diagnosis. He is a veteran of the Vietnam War, and has lived a mostly healthy lifestyle. He is not someone who is interested in sharing his feelings yet the nurse caring for him understands he needs nursing intervention related to physical, emotional, psychological, social, and spiritual distress as he is about to embark on a long journey filled with extensive diagnostic testing and treatment regimens. Which one of the following interventions should his nurse utilize in managing his psychosocial issues? A. Encourage the patient to verbalize his feelings about the disease and the treatment B. Encourage the patient to talk with his family since his loved ones know him best C. Refer the patient to pastoral care D. Tell the patient there is "noting to worry about" so there is no sense in getting worked up

Answer: A Rationale: The correct nursing intervention related to physical, emotional, psychological, social, and spiritual distress is to encourage the patient to verbalize his feelings about the disease and the treatment. While nurses are encouraged to engage the family in coping options, the intervention should be done jointly between the patient and the family, while validating effective mechanisms. The patient should not be referred to pastoral care, unless the patient is requesting to see a pastor, but the nurse should refer the patient to a mental health specialist, community resources, and support groups run by established associations such as the Leukemia and Lymphoma Society, the American Cancer Society, and the International Myeloma Foundation, as needed. Other interventions including teaching the patient and family to identify, manage, and report symptoms, and providing pharmacologic and nonpharmacologic interventions to manage side effects.

Chapter 24 Skin Cancers 1. A nurse is caring for N.M., who is a 72-year-old female patient, and has had several basal cell carcinomas (BCC) diagnosed on her face and arms over the years. The nurse knows that the predominant risk factor for developing BCC is which one of the following? A. sunlight overexposure B. tobacco smoking C. family history D. young age

Answer: A Rationale: The major risk factor for BCC is exposure to the ultraviolet radiation of sunlight, specifically, intermittent exposure early in life. BCCs develop primarily on sun-exposed skin. They are rarely found on palmoplantar surfaces and never appear on the mucosa. Approximately 80% arise on the head and neck area. They tend to be slow growing and arise without precursor lesions. BCCs can be locally invasive tumors. Family history of skin cancer is associated with increased risk but is not the major cause of BCC. Tobacco smoking and young age are not considered risk factors. Risk increases with older age (> 65 years).

6. A nurse is caring for G.F., a 37-year-old male patient, who has a high-grade non-Hodgkin lymphoma with localized disease. In a meeting with the physician, the patient asks about his prognosis. The nurse caring for G.F. would most likely expect the provider to respond that the disease: A. "We could achieve a cure with combination therapy and you have an overall survival of 5 years." B. "You will most likely relapse within two years, and, unfortunately, your overall cure rate is only 10%." C. "We have encouraging news. You have a greater than 80% cure rate and a survival time of more than 20 years." D. "This disease is completely curable, after you have undergone an autologous stem cell transplant."

Answer: A Rationale: The majority of patients who have a high-grade, localized disease who receive radiation plus chemotherapy or combination chemotherapy alone, have an overall survival at 5 years, which is over 60%. Patients who have aggressive NHL have a cure rate of 50%; however, they can expect to relapse within 2 years after therapy. Those patients with an 80% cure rate are those who are diagnosed with Hodgkin's Lymphoma and who are treated with combination chemotherapy and/or radiation therapy. High-dose chemotherapy (HDCT) followed by an autologous stem cell transplant is sometimes utilized in Hodgkin's Lymphoma or NHL, which is refractory or recurrent, but does not ensure a cure.

12. An oncology nurse has volunteered her time at a community health fair and is working a booth on the prevention of various cancers. Included in her materials are teaching materials on how to reduce the possibility of HIV transmission. Which one of the following would most likely be included in any of the educational materials she plans to hand out? A. Provide education about the use of latex condom with a water-based lubricant to reduce risk. B. Provide education about the use of latex condom with a petroleum-based lubricant to reduce risk. C. Provide education about the best way to share household toiletries such as razors and other personal items. D. Sharing information on mixing a solution of 1-part household bleach to 10 parts water for use in clean-up of emesis or other body fluid spills, with or without using gloves.

Answer: A Rationale: The nurse should provide education about the use of latex condoms with a water-based lubricant to reduce risk. A water-based lubricant is recommended because petroleum-based lubricants or cosmetic creams weaken the condom, greater increasing the chance of HIV transmission. To decrease the risk of transmission, a latex condom should be used during every episode of vaginal, rectal, or oral intercourse. Personal hygiene items - such as a toothbrush or a razor - should not be shared, so the best method is to avoid sharing altogether. The solution of 1 part household bleach to 10 parts water during cleanup of emesis or other body fluid spills is correct and can be used, but the person cleaning should always wear gloves for protection against the spread of disease.

5. A 27-year-old male patient has been newly diagnosed with grade III oligodendroglioma and is scheduled to receive chemotherapy teaching from his oncology nurse. The most important time sensitive educational intervention that she can provide him would include which one of the following? A. sperm banking B. lifting of driving restrictions C. obtaining a second opinion D. hospice services

Answer: A Rationale: The oncology nurse recognizes that a young man with a grade III oligodendroglioma can have a life expectancy of more than 10-15 years with treatment. Thus, while discussing driving, hospice, and outside opinions are of importance at different care points, the most timely education for this young man relative to his chemotherapy treatment is the option of sperm banking PRIOR to starting his chemotherapy treatment.

12. Breast milk is produced by which one of the following? A. terminal duct lobular units B. adipose tissue C. sebaceous tissue D. primary duct units

Answer: A Rationale: The terminal duct lobular units (TDLUs) produce breast milk. Adipose tissue becomes more prominent after menopause. Sebaceous tissues are microscopic glands in the skin that secrete an oily substance known as sebum. There are no primary duct units.

Chapter 13 Breast Cancer 1. The two most important risk factors that make a person more susceptible to breast cancer include age and which one of the following? A. gender B. race C. reproductive/hormonal factors D. pregnancy

Answer: A Rationale: There are multiple risk factors for developing breast cancer. Breast cancer is 100 times more common in woman than men. The incidence of breast cancer is higher with aging, only 5% of women before the age of 40 develop breast cancer, but 60% of breast cancer cases occur after age 60 years or older. Breast cancer is 100 more times more common in women than in men. A person's family history also increases risk. Approximately 10% of all breast cancers are due to genetic susceptibility. Pregnancy after the age of 30 or nulliparity is associated with an increased risk.

10. A patient with a family history of breast cancer has had genetic testing with "23 and Me" and reports her result was "negative". Which of the following information should be discussed with her? A. This tests for BRCA1/2 genetic testing only and includes three mutations. B. Breast cancer predisposition testing from this test is not United States Food and Drug Administration approved. C. Direct-to-consumer testing is approved for use in diagnosis and treatment of breast cancer. D. All direct-to-consumer testing is the same.

Answer: A Rationale: This test includes only the three BRCA1/2 (selected variants) mutations most common in persons of Ashkenazi descent. These are the most common out of thousands of mutations which are not included in the direct-to-consumer test. B is incorrect as it is FDA approved. C is incorrect as it is not FDA approved for diagnosis or clinical decision making in breast cancer. D is incorrect as Only 23 and ME is FDA approved but there are other types of direct to consumer genetic testing.

8. J.B. is a 46-year-old male patient, whose chest radiography done in the emergency department reveals mediastinal widening. A chest CT is done, and a large mediastinal mass is detected. Upon axillary lymph node biopsy, a large cell follicular lymphoma is diagnosed. Which one of the following diagnostic tests is not necessary to determine treatment options? A. Obtain a 24-hour urine. B. Determine whether he lymph node biopsy is CD 20 +. C. Obtain a CT scan of the abdomen and pelvis. D. Perform a bilateral bone marrow biopsy and aspirate.

Answer: A Rationale: To complete staging for non-Hodgkin lymphoma, a computed tomography scan of the chest, abdomen, and pelvis must be completed. In addition, a bilateral bone marrow biopsy and aspirate are done to determine whether bone marrow disease is present. To diagnose lymphoma, a lymph node biopsy is required to determine pathology. If the pathology reveals a CD 20 tumor, the patient may receive rituximab (Rituxan, a monoclonal antibody specific for CD 20 cells, as part of the chemotherapy regimen. The correct answer, then, is A. A 24-hour urine test is not necessary in staging a Hodgkin's Lymphoma.

6. K.S. is a 54-year-old female with breast cancer and multiple brain metastases is who scheduled to initiate whole-brain radiation therapy (WBRT). The oncology nurse understands the best description of this treatment's intent is which one of the following? A. palliative B. curative C. adjuvant D. neoadjuvant

Answer: A Rationale: WBRT is indicated when there are 4 or more brain metastases and the goal of therapy is palliative (to reduce symptoms and promote comfort care). WBRT is not curative. While pain management and improved or stabilizing neurologic status may be a potential benefit of WBRT, these both fall under the palliative intent of therapy. Adjuvant therapy in breast cancer usually refers to treatment given after surgery to remove the breast cancer. Neoadjuvant therapy is therapy given prior to breast surgery.

3. The oncology nurse recognizes that the most important first-line treatment for a malignant primary brain tumor is which one of the following? A. maximal surgical tumor resection B. chemotherapy C. antiepileptic medications D. corticosteroids

Answer: A Rationale: While corticosteroids may be administered preoperatively, and antiepileptic medications may be given perioperatively, they are to control symptoms of the tumor and are not a primary treatment for the tumor. The most important therapy for a primary brain tumor is maximal surgical resection. Chemotherapy is not effective in many types of brain tumor.

7. Every attempt should be made to continue chimeric antigen receptor T-cell therapy (cART) through antineoplastic therapy. While a nurse's patient with AIDS-related diffuse large-cell B-cell lymphoma (DLBCL) is receiving R-CHOP, the nurse should do which one of the following? A. Monitor for overlapping toxicities that may occur with combination therapy. B. Administer steroids to decrease the risk of inflammatory response. C. Administer Shingrix to decrease risk of varicella- zoster virus reactivation. D. Hold antineoplastic therapy in the setting of low CD4 counts.

Answer: A Rationale: cART and antineoplastic agents may have similar toxicity profiles (i.e. diarrhea, hepatotoxicity, pancreatitis, QT prolongation, etc.) and combination therapy may compound the toxicities when utilizing combination therapy for treatment. Therefore, patients should be monitored for overlapping toxicities when undergoing combination therapy. Steroid use increases the risk of inflammatory response (i.e. IRIS) rather than decreasing inflammation. Vaccines should be modified during or after cancer treatment due to continued immune defect, while antineoplastic therapy should continue to be administered in the setting of low CD4 counts as these counts are a temporary condition.

14. Which one of the following is the primary treatment for nasopharyngeal cancer? A. The primary treatment is radiation B. The primary treatment is preoperative radiation or permanently placed iodine-125 seeds C. The primary treatment is brachytherapy D. The primary treatment is a low dose of radioactive iodine given after surgery

Answer: A Treatment for nasopharyngeal cancer is primarily radiation. Surgery for this type of cancer is recommended to be avoided because the area is too close to vital structures of the brain. Select patients who do not respond to radiation therapy are treated with base-of-skull resection of tumor procedure. Preoperative radiation or permanently placed iodine-125 seeds are the primary treatment in debulking large or unresectable lesions. Brachytherapy is a treatment for lesions of the anterior and posterior tongue, the floor of mouth, and the nasal vestibule. According to the National Comprehensive Cancer Network (NCCN), a low dose of radioactive iodine given after surgery for thyroid cancer destroys (ablated) residual thyroid tissue as effectively as a higher dose, but with fewer side effects and less exposure to radiation.

18. The protein coding section of a gene is referred to as A. Exon B. Codon C. Intron D. Autosome

Answer: A Rationale: Exons are protein-coding segments of a gene. Introns are non-protein-coding segments, the sequence-interrupting piece of a gene. A codon is a sequence of three mRNA nucleotides (e.g., ACG) yielding one (threonine) of the 20 amino acids. An autosome is any chromosome that is not a sex chromosome.

14. F.D. is a 45-year-old woman having a TAH BSO for ovarian cancer. She has been experiencing irregular menses prior to surgery. Possible complications she might experience include which one of the following? A. alternating constipation and diarrhea B. vaginal drying and pelvic tissue atrophy C. decreased risk of cardiovascular disease D. changes in urinary function

Answer: B Ms. D is perimenopausal. Following surgery, she will be considered menopausal. Surgery and radiation therapy of the abdomen/pelvis and associated pretreatment and posttreatment care, including hypoestrogenism after BSO, which may induce hot flashes, mood, changes, vaginal dryness, pelvic tissue atrophy, osteoporosis, and increased cardiovascular disease (CVD) risk. Alternating constipation and diarrhea as well as change in urinal function are not common complications following a hysterectomy. Risk of cardiovascular disease is increased in postmenopausal women especially those such as Ms. D who are experiencing an early menopause.

Chapter 10 Genetic Risk Factors 1. Application of the Central Dogma of molecular biology to oncology nursing practice is important because: A. canines have the same DNA nucleotides as humans. B. it explains the production of protein for all body functions. C. DNA and RNA contain identical nucleic acids for genetic information important in genetic testing in hereditary risk. D. RNA to DNA to protein explains the chain of events for protein production.

Answer: B Rationale: "DNA makes RNA and RNA makes protein," explains the production of protein for all body functions". This knowledge aids in the education of patients and families about their inherited genetic testing results. A is incorrect because, while this is an accurate statement, it is not necessary information for oncology nursing practice. D is also false as "DNA makes RNA and RNA makes protein" directs the protein production in the body. C is also false as RNA contains Uracil instead of the Thymine contained in DNA.

5. An oncology nurse is caring for a newly diagnosed patient with osteosarcoma who has "skip metastasis". The nurse is aware that this occurs when A. cells bypass one organ and metastasize in another B. cells bypass the first node and reach more distant sites C. cells spread into nearby capillary beds or pulmonary arteriovenous shunts D. tumor cells embed into distant arteries

Answer: B Rationale: "Skip metastasis" is an example tumor cell dissemination throughout the lymphatic system. "Skip metastasis" occurs when cells bypass the first lymph node and reach more distant sites. Tumors bypassing one organ and metastasizing in another is not an example of a pathway in which tumor cells disseminate. Tumor cells spreading through pulmonary capillary beds or pulmonary arteriovenous (AV) shunts is an example of arterial spread. Arteries have thick walls, and are not able to be penetrated as veins are.

9. A "variant of unknown significance" (VUS) has which of the following characteristics: A. It is identified when a cancer risk has been established. B. A VUS identifies a genetic change in which the association with cancer risk cannot be established. C. Once identified, a VUS maintains that label forever. D. A VUS is an uncommon genetic finding.

Answer: B Rationale: A VUS is a change in the genetic material for which there is not enough data to determine if it is a harmful or harmless change in the genetic material. A is incorrect as a VUS is identified when a cancer risk has NOT been established. C is also incorrect as a VUS label can change to pathogenic or benign based on information identified in new types of genetic testing. D is incorrect as a VUS can be a fairly common finding.

12. Which of the following describes the physical alteration and nursing implications for the hemilaryngectomy procedure? A. Little to no physical alteration and minimal bleeding. B. Vertical excision of one true and one false cord, hoarse voice, and minimal to no swallowing problems. C. Partial or total en-bloc resection of the cavity, and may include the ethmoid sinus, and lateral nasal wall, and requires daily care to cavity and placement of obturator. D. Surgical approach to inaccessible midfacial and extensive paranasal sinus and nasopharyngeal lesions. May have facial defect and cranial nerve (III, IV, V) deficits.

Answer: B Rationale: A hemilaryngectomy involves a vertical excision of one true and one false cord and the underlying cartilage. This procedure can give the patient a hoarse voice but leads to minimal to no swallowing problems. A laser has the least implications of any of these procedures, with little to no physical alterations and minimal bleeding. A maxillectomy involves partial or total en-bloc resection of the cavity. This procedure may include the ethmoid sinus, lateral nasal wall, palate, and floor of the orbit. Nursing implications include, postoperatively, maxillofacial prosthodontist making a dental obturator to fill the large surgical defect and to facilitate swallowing. Requires daily care to cavity and placement of obturator. A craniofacial or skull base resection is a surgical treatment to inaccessible midfacial and extensive paranasal sinus and nasopharyngeal lesions. This treatment may have facial defects and cranial nerve (III, IV, V) deficits.

Chapter 21 Multiple Myeloma 1. Which one of the following risk factors have been found to be associated with the incidence of newly diagnosed multiple myeloma (MM)? A. employment status B. history of monoclonal gammopathy of undetermined significance (MGUS) C. female gender D. exposure to Epstein-Barr virus

Answer: B Rationale: A known risk factor for developing multiple myeloma is a history of monoclonal gammopathy of undetermined significance (MGUS). Additionally, another risk factor includes exposure to the herbicide and defoliant Agent Orange that was used by the U.S. military during deployment in the Vietnam War during the 1960s and early 1970s. Other risk factors include exposure to ionizing radiation (including low-level radiation, which places radiologists and those working in the nuclear power industry at risk), exposure to certain metals (especially nickel), agricultural chemicals, benzene, and petroleum products, aromatic hydrocarbons, and silicone. Multiple myeloma has also been linked to a family history of the disease, obesity, and immunologic issues (patients with AIDS have been associated with developing multiple myeloma). Finally, ethnicity has been shown as a risk factor, with multiple myeloma with twice the incidence in African Americans than in their Caucasian counterparts. Exposure to EBV is a risk factor for lymphoma but not specific to multiple myeloma. The employment status of a person or female gender are not known risk factors.

12. Which one of the following is a nursing implication when trying to maximize and promote a patient's health and safety after surgery? A. Teaching a patient to manage and identify symptoms, including providing recommendations on when to report symptoms. B. Monitoring vital signs, hemoglobin, hematocrit, kidney function tests, and urine output. C. Teaching patients how to perform coping skills to control anxiety and fear. D. Monitoring patients for signs of distress.

Answer: B Rationale: A recommendation to maximize patient safety postoperatively is monitoring vital signs, hemoglobin, hematocrit, kidney function tests, and urine output. These are critical measures when determining a patient's condition after surgery. Teaching a patient to manage and identify symptoms, including providing recommendations on when to report symptoms, occurs during patient education regarding follow-up care and surveillance, and not as a safety measure after surgery. Teaching patients how to perform coping skills to control anxiety and fear is also not a safety measure; however, nurses do teach patients about pulmonary hygiene, including how to perform coughing and deep breathing exercises. Finally, monitoring patients for signs of distress is not a safety measure, though nurses must monitor a patient's pain level after surgery in order to provide adequate pharmacologic and nonpharmacologic pain relief measures.

5. D.R. is a 44-year-old male who has a new diagnosis of high-risk acute promyelocytic leukemia. D.R. has no known comorbidities. His nurse knows he will begin treatment with a regimen of; all-trans-retinoic acid (ATRA) plus which one of the following? A. arsenic trioxide B. arsenic trioxide plus anthracycline C. arsenic trioxide plus gemtuzumab ozogamycin D. arsenic trioxide plus intrathecal chemotherapy

Answer: B Rationale: ATRA arsenic trioxide anthracycline is recommended in high-risk disease in the absence of cardiac disease. ATRA arsenic trioxide is given with or without anthracycline in low-risk disease. Gemtuzumab ozogamicin is used as a single agent in high-risk, relapse, or inability to tolerate arsenic trioxide due to QT prolongation. Intrathecal chemotherapy is used in consolidation therapy for patients with high-risk APL in combination with ATRA arsenic trioxide anthracycline.

8. A characteristic of HIV-related lymphoma includes which one of the following? A. a CD4 count of 400/mm3 B. an active EBV infection C. the presence of CD20 marker D. an early manifestation of HIV infection

Answer: B Rationale: An active EBV infection is present in 44% to 67% of HIV lymphomas. In HIV-related lymphoma, the CD4 count is typically less than 200/mm3, not 400/mm3, it lacks the CD20 marker, and is a late manifestation of HIV infection. 9. Answer: CRationale: Ocular involvement occurs in 20% of patients diagnosed with primary central nervous system lymphoma, and commonly have multifocal lesions. HIV-infected patients do not have extensive bone marrow involvement, nor do they have other organ/tissue involvement. This patient population also has a low CD4 count and do not generally have concurrent CMV but EBV infection.

4. When is it safe for a patient with a history of gestational trophoblastic neoplasia to attempt to conceive? Choose from one of the following statements. A. It is safe to attempt to conceive as soon as the patient's human chorionic gonadotropin (hCG) levels have started to respond to chemotherapy. B. It is safe to attempt to conceive after the patient has completed one year of surveillance. C. It is safe to attempt to conceive after the patient's hCG levels have normalized for 6-8 weeks and menses have become regular. D. It is safe to attempt to conceive as soon as the patient's menses are regular, however, the patient will most likely experience difficulty conceiving at all due to the chemotherapy treatment's deleterious effects on fertility.

Answer: B Rationale: Chemotherapy is effective with good cure rates and has not been shown to decrease fertility after treatment for GTN. Patients should wait at least 12 months after completing treatment before conceiving, as (1) it is unsafe to conceive while undergoing or immediately after chemotherapy treatment, and (2) most relapses will occur within as 12-month timeframe.

4. An example of how tumor cells can evade the adaptive immune system would include which one of the following? A. becoming resistant to chemotherapy through drug activation B. promotion of T-cell exhaustion by upregulating checkpoint molecules C. the innate immune system keeping the disease in check D. increasing antigens that are recognized by the adaptive immune system

Answer: B Rationale: Chemotherapy resistance occurs as a result of changes in tumor biology, such as drug inactivation, drug target alteration, drug efflux, DNA damage repair, and cell death inhibition. These are changes that occur with the tumor's interaction with the chemotherapeutic agent and not with the host's immune system. Response B reflects one of many examples of how persistent tumor clones have acquired the ability to "hide" from the immune system, leading to continued reproduction and cancer progression. By promoting T cells to increase PD1/PDL1 on their surface, tumor cells are decreasing T-cell immune surveillance and reproduction, which allows for continued growth of the tumor. Recently developed immunotherapeutic medications, called checkpoint inhibitors, use this known concept of tumor biology to block tumor cells from promoting hosts' T-cell exhaustion, which stimulates the adaptive immune system. The innate immune system is the body's first line of defense against host invaders and works with the adaptive immune system in tumor surveillance. When the innate immune system can no longer keep the tumor in check (equilibrium phase), the adaptive immune system can function independently to perform ongoing immune surveillance. Another method of immune system evasion is decreasing or losing antigens, not increasing, on the tumor's surface. When this occurs, the adaptive immune system can no longer recognize the tumor cell. This leads to ongoing progression/reproduction of cancer.

9. Which one of the following is a definition of carcinogenesis? A. The creation of new blood vessels from existing ones to provide nutrients and remove waste products. B. The transference of normal cells into cancer cells through a complex and dynamic process that starts with mutations in regulatory cells and is promoted by genomic instability, inflammation, and interactions within the tumor microenvironment. C. The process which causes epithelial cells to lose cell polarity and cell-cell adhesion and have invasive properties so that they can become mesenchymal cells. D. A mechanism that may change the activity of a gene without changing the sequence of DNA.

Answer: B Rationale: During carcinogenesis, normal cells are transferred into cancer cells through a complex and dynamic process that starts with mutations in regulatory cells and is promoted by genomic instability, inflammation, and interactions within the tumor microenvironment. Angiogenesis is the creation of new blood vessels from existing ones to provide nutrients and remove waste products. Normal cells have a developmental regulatory program called epithelial mesenchymal transition (EMT). This process causes epithelial cells to lose cell polarity and cell-cell adhesion and have invasive properties so that they can become mesenchymal cells. This process is involved in mesoderm formation and neural tube formation during embryogenesis. It has also been found to play a role in wound healing and organ fibrosis Epigenetics describes a mechanism that may change the activity of a gene without changing the sequence of DNA.

8. Which one of the following referrals would a patient require after a neck dissection for treatment for head and neck cancer? A. occupational therapy B. physical therapy C. pain management D. gastroenterologist

Answer: B Rationale: During neck dissection, the patient's spinal accessory nerve and the sternocleidomastoid muscles may be resected. For the patient to regain range of motion and strength, the patient is referred to physical therapy. The patient is not likely to have significant pain issues by time of discharge nor do they require a gastroenterology consult as a routine referral. Occupational therapy is not a typical referral for neck dissection patients. Speech therapists play an integral role both preoperative and postoperatively to assist with issues in speech and swallowing.

Chapter 20 Lymphoma 1. An oncology nurse is caring for L.J, a 25-year-old male with favorable Hodgkin's Lymphoma diagnosis. After speaking with his healthcare provider, L.J. asks the nurse about his standard course of treatment. The nurse explains that he will receive which one of the following? A. five cycles of chemotherapy plus radiation therapy B. two to three cycles chemotherapy, plus radiation therapy C. high-dose chemotherapy and autologous bone marrow transplant D. Palliative chemotherapy and radiation therapy

Answer: B Rationale: Early favorable Hodgkin's Lymphoma is a clinical stage I or II without any additional risk factors. The patient has an early favorable stage Hodgkin's Lymphoma, which requires limited amount of chemotherapy (usually two to three cycles) plus involved field radiation therapy. For patients with unfavorable stages, a moderate amount of chemotherapy (four cycles) plus involved field radiation is required. High-dose chemotherapy followed by autologous bone marrow transplant may be required for patients who have relapsed/refractory disease. Combination chemotherapy and radiation is associated with long-term survival in more than 80% of patients. Palliative chemotherapy and radiation therapy are not the correct treatment options for patients who have favorable Hodgkin's Lymphoma.

7. A common inclusion criteria for eligibility used broadly in oncology clinical trials is termed as which one of the following? A. geographic area of residence B. performance status C. no prior research participation D. number of children

Answer: B Rationale: Eligibility criteria are characteristics that potential participants must meet to be enrolled into the trial and includes demographic, disease-specific, and treatment-related variables. These include inclusion and exclusion criteria. Common inclusion criteria that must be satisfied before an oncology patient can enter a trial includes performance status using indicators such as laboratory values, Eastern Cooperative Oncology Group (ECOG) or Karnofsky Performance Status. Other common inclusion criteria include stage and/or status of tumor, presence of measurable disease, and presence or absence of biomarkers. Geography or place of residence is not usually an eligibility criteria, although proximity to the trial may make participation easier. Some studies may not allow previous research participation; this can vary from study to study. The number of children a potential study participant has is seldom an eligibility criteria.

2. According to 2018 statistics from the American Cancer Society, colorectal cancer is the third leading cause of cancer-related deaths in men and in women, and the second most common cause of cancer deaths when men and women are combined. Mr. P. is a 55-year-old man who is has been diagnosed with metastatic colon cancer. The nurse caring for Mr. P. is aware that the signaling pathway that may be playing a role in his metastases is: A. vascular endothelial growth factor B. epidermal growth factor receptor C. medial growth factor D. nerve growth factor

Answer: B Rationale: Epidermal growth factor receptors participate in colon cancer development and play a role in some colon cancer metastases. Vascular endothelial growth factors may cause tumor cells to spread to regional lymph nodes. Nerve growth factors are primarily involved in the regulation of growth, maintenance, proliferation, and survival of certain target neurons, especially those that transmit pain, temperature, and touch sensations. There is no medial growth factor.

11. D.J. is a 52-year-old male with a diagnosis of non-small cell lung cancer (NSCLC). He will begin treatment with molecular targeted therapy. The nurse treating him understands that molecular targeted therapy has which one of the following considerations? A. Is not known to be effective in treating individuals with genetic mutations. B. Erlotinib is now considered first-line therapy for individuals with advanced, recurrent, or metastatic non-squamous NSCLC. C. Bevacizumab is recommended in select patients with advanced NSCLC. D. Does not seem likely to impact therapies for pathways of mutation.

Answer: B Rationale: Erlotinib is considered first-line therapy for individuals with advanced, recurrent, or metastatic NSCLC, so that could be an agent used to treat D.J. Molecular-targeted therapy is known to be effective in treating individuals with a genetic mutation and is promising for future developments of targeted therapies for specific pathways of mutation. Bevacizumab is recommended in select patients with advanced NSCLC but in addition to chemotherapy, and not as a single treatment, as misrepresented in the incorrect question.

Chapter 14 Gastrointestinal Cancers 1. Which one of the following is part of the diagnostic work-up for esophageal cancer? A. Colonoscopy B. Esophagogastroduodenoscopy C. Brain MRI D. Abdominal ultrasound

Answer: B Rationale: Esophagogastroduodenoscopy (EGD) is an endoscopy examination to examine the lining of the esophagus, stomach, and first part of the small intestine. Biopsies may be taken to evaluate for the presence of malignancy. Colonoscopy is a screening test for colorectal cancer. An MRI of the brain and abdominal ultrasound are not part of a routine work-up for esophageal cancer. Other diagnostic modalities for esophageal cancer include a CT or a PET scan of the chest and abdomen, endoscopic ultrasound, and bronchoscopy.

2. Which one of the following factors makes a patient more likely to have a genetic abnormality based on family history of breast cancer? A. History of multiple breast surgeries B. First-degree relative with breast cancer C. Age of menopause or menarche prior to diagnosis D. Nulliparity

Answer: B Rationale: Family history of a first-degree relative having breast cancer is a consideration for genetic evaluation. This is especially important in women with a first degree or second-degree relative with breast cancer diagnosed before the age of 50, multiple family members with breast cancer, or a family history of ovarian cancer. Breast biopsy, reproductive factors such as nulliparity or age at menarche, first pregnancy or menopause are personal, not hereditary, risk factors for developing breast cancer.

5. Jill is an oncology nurse focusing on patients with head and neck cancer. Her nursing care of her patients with head and neck cancer should specifically focus on which one of the following? A. neutropenia B. swallowing C. skin care D. lymphedema

Answer: B Rationale: Focused nursing care of head and neck cancer patients includes respiration, speech, swallowing, trismus (restriction in the opening of the mouth), and hormone regulation. Depending on the patient's overall health maintenance, nursing care can also include attention to neutropenia, skin care, and lymphedema. However, those conditions are not the specific focus of nursing care for patients with head and neck cancer.

2. Ewing family tumors (EFT) are associated with: A. distant metastasis B. adolescence C. age over 65 years D. hormonal therapy

Answer: B Rationale: For EFTs, 50% of patients diagnosed are adolescents. Approximately 50% of patients diagnosed are adolescents. EFTs are associated with retinoblastoma and skeletal anomalies. They tend to be highly malignant (approximately 25% with metastases at time of diagnosis to lungs, lymph nodes, other bones). The five-year disease-free survival rate is approximately 73% because of effective multimodality therapies, and precision in surgery. EFTs are characterized as local or regional to the bone. EFTs, a type of bone cancer, are not associated with hormonal therapy.

13. A patient will be undergoing urologic diagnostic testing. Which one of the following nursing interventions should the nurse perform for a radiographic examination of the kidneys, ureter, and bladder (KUB)? A. Assess the patient for history of allergy to iodine dyes or contrast media before performing the test. B. Explain to the patient the need to lie flat on examination table. C. Observe the patient for a reaction to anesthetic or analgesic. D. Monitor the patient for bleeding, and symptoms of a urinary tract infection.

Answer: B Rationale: For a radiographic examination of the kidneys, ureter, and bladder (KUB), the nurse should instruct the patient to let flat on the examination table. Accessing the patient for a history of allergies to iodine dyes or contact media before testing is a nursing intervention instruction for an excretory urography test. For a retrograde urography diagnostic test, nurses are instructed to observe the patient for a reaction to anesthetic or analgesic, and monitor for bleeding, symptoms of a urinary tract infection, dysuria, or difficulty voiding after the test has been completed.

3. The oncology nurse is caring for a 29-year-old female patient newly diagnosed with bilateral breast cancer. Which of the following would raise suspicion for hereditary breast and ovarian cancer (HBOC) syndrome? A. Maternal aunt and paternal uncle with a history of brain cancer at unknown ages. B. Mother was diagnosed with ovarian cancer at age 33 years. C. Brother was diagnosed with testicular cancer at age 25 years after he served in the military during Vietnam. D. 4-year-old nephew diagnosed with leukemia.

Answer: B Rationale: HBOC is associated with ovarian cancer especially when it occurs before age 50. HBOC is also associated with early onset breast cancer (before age 50) especially when there are multiple family members diagnosed with breast cancer, triple negative breast cancer diagnosed before age 60 or a family history of pancreatic cancer or metastatic prostate cancer. A is incorrect because these individuals are each from both maternal and paternal lineages. C is also incorrect, because even though her brother is young, testicular cancer is not associated with HBOC and testicular cancer is usually diagnosed in younger men. D is incorrect because childhood leukemia is not associated with HBOC.

Chapter 16 Head and Neck Cancers 1. The classification of head and neck cancers includes which one of the following cancers? A. esophagus B. thyroid C. brain D. bone

Answer: B Rationale: Head and neck cancers include cancers of the oral cavity, oropharynx, nasal cavity, paranasal sinuses, nasopharynx, larynx, hypopharynx, and salivary glands; as well as cancers of the thyroid and parathyroid. The category of head and neck cancers does not include cancers of the esophagus, brain, or bone.

10. K. L. is a 47-year-old male patient who has been diagnosed with advanced prostate cancer. He arrives at the physician's office to discuss treatment options with his nurse. Options for this patient include which one of the following? A. radical prostatectomy B. hormonal manipulation C. insertion of radioactive seeds into the prostate D. cryosurgery to freeze the involved prostatic tissue

Answer: B Rationale: Hormonal manipulation is the accepted standard for treating patients with metastatic prostate cancer. The other options listed - radical prostatectomy, brachytherapy with radioactive seed placement into the prostate, and cryosurgery - are used to treat patients with early-stage prostate cancer.

3. Lifestyle factors such as nutrition, health, and smoking may result in infection with other strains of HIV and ________. Choose one of the following that completes the statement. A. slow the disease progression B. influence the course of infection C. may hasten the disease progression D. are seen in approximately 37% of cases

Answer: B Rationale: Lifestyle factors including nutritional status, overall health, and tobacco use may influence the course of infection. These lifestyle factors neither slow nor do they hasten the disease progression, as it is difficult to distinguish between comorbid infection and a true causal relationship. There is an increased risk of infection in uncircumcised males related to dendritic cells on the foreskin. Other factors that might influence the progression of the disease might include the presence of cytomegalovirus (CMV), Epstein-Barr virus (EBV), hepatitis C virus, human papillomavirus (HPV), herpes simplex 6 (HSV- 6), herpes simplex 8 (HSV-8), and other viruses.Approximately 67% of cases in gay, bisexual, and other men who have sex with men comprises half of newly infected HIV infection and half of people living with the disease, and not the 37% of cases listed in answer D, making that answer incorrect as well.

20. Mutations in the MSH2 gene are associated with cancers of the A. lung B. ovary C. sarcoma D. thyroid

Answer: B Rationale: Lynch syndrome, which was previously known as hereditary nonpolyposis colorectal cancer [HNPCC]), is associated with mutations in the following genes: MLH1, MSH2 (including methylation due to EPCAM deletion), MSH6 and PMS2. Lynch syndrome is characterized by microsatellite instability (MSI) due to defective mismatch repair. Cancers associated with Lynch syndrome include cancers of the colon, rectum, stomach, small intestine, esophagus, biliary tract, brain, endometrium, and ovary. Other cancers at elevated risk are transitional cell carcinoma of the ureters and renal pelvis and pancreatic cancer. Lynch syndrome is not typically associated with cancers of the lung or thyroid or sarcomas.

19. Which of the following hereditary cancer syndromes is inherited in an autosomal recessive fashion? A. Hereditary retinoblastoma B. MUYTH associated polyposis C. Hereditary diffuse gastric cancer D. Multiple endocrine neoplasia type 1

Answer: B Rationale: MUTYH-associated polyposis (MAP) is an autosomal recessive hereditary cancer syndrome and is associated with colon cancer and duodenal cancer, as well as colon, duodenal, and gastric fundic gland polyps, osteomas, sebaceous gland adenomas, and pilomatricomas. Polyp counts range from a few to > 1000 with biallelic MUTYH mutations. Hereditary retinoblastoma, hereditary diffuse gastric cancer, and multiple endocrine neoplasia are all inherited in an autosomal dominant fashion. Hereditary diffuse gastric cancer found on the CDH1 gene is associated with diffuse gastric cancer, lobular breast cancer, adenocarcinoma and epithelial ovarian cancer, prostate and signet ring colon cancer. Hereditary retinoblastoma is found on the RBI gene and is associated with malignant tumors of the retina, usually occurring before age 5. A family history of retinoblastoma, bilateral retinal tumors, and multifocal tumors have the highest chance to have hereditary retinoblastoma. Individuals with hereditary retinoblastoma also have an increased risk for pinealoblastoma, osteosarcomas, sarcoma, and melanoma. Multiple endocrine neoplasia type 1 (MEN1) is found on the MEN1 gene. It is associated with endocrine and nonendocrine tumors, including tumors of the parathyroid glands, pituitary gland, and the pancreas

7. Which one of the following is a characteristic of Merkel cell carcinoma? A. Develops primarily on sun-exposed skin; rarely found on palmoplantar surfaces and never appears on the mucosa B. Presents as papules, plaques, and cyst-like structures or pruritic tumors on the lower extremities C. Often presents as a new or enlarging lesion that may bleed, weep, be tender, or be painful D. Can develop at sites of chemical exposure or chronic trauma

Answer: B Rationale: Merkel cell carcinoma (MCC) presents as papules, plaques, and cyst-like structures or pruritic tumors on the lower extremities. MCC most commonly presents as an erythematous or violaceous, tender, dome-shaped nodule on sun-exposed areas on the head or neck of an elderly white male. Develops primarily on sun-exposed skin and rarely found on palmoplantar surfaces and never appears on the mucosa are characteristics of a basal cell carcinoma (BCC). A BCC can also develop at sites of chemical exposure or chronic trauma. Cutaneous squamous cell carcinoma (cuSCC) often presents as a new or enlarging lesion that may bleed, weep, be tender, or be painful.

7. Modifiable risk factors for penile cancer include which one of the following? A. hepatitis B vaccination B. tobacco cessation C. circumcision is recommended after puberty D. avoid retracting the foreskin while cleaning the glans

Answer: B Rationale: Modifiable risk factors for penile cancer include HPV vaccination to prevent HPV infection, prevention of HIV infection, circumcision before puberty, and tobacco cessation The foreskin should be retracted when cleaning the glans to maintain adequate hygiene in uncircumcised patients. Penile cancer is more common in parts of Asia, Africa, and South America than in North America or Europe. It is a rare cancer in the U.S. with usual presentation at 50 to 70 years. HIV/HPV infection (positive in 60%-80% of penile cancers, type 16, 18) is a modifiable risk factor. Other known risk factors include phimosis, balanitis, chronic inflammation, penile trauma, lack of circumcision, lichen sclerosis, tobacco use, and poor hygiene.

4. Molecular classification for metastatic colorectal cancer includes which one of the following? A. Programmed death ligand-1 B. KRAS/NRAS C. Estrogen receptor/progesterone receptor D. EGFR mutation

Answer: B Rationale: Molecular classification in colon cancer includes KRAS/NRAS (in patients with metastatic disease), BRAF (in patients with metastatic disease), and MMR or MSI. PDL-1 and EGFR are used in the molecular classification of lung cancer. ER/PR (estrogen/progesterone) are used in the molecular classification of breast cancer.

3. G.T. is a 35-year-old patient, who is a one-half pack-per-day smoker with a history of PID. She was recently diagnosed with advanced ovarian cancer. She states that "cancer always happens to us," in reference to her elder sister whom is a breast cancer survivor. She is concerned that her 10-year-old daughter could be at risk for ovarian cancer in the future, and asks her oncology nurse for advice. The nurse knows which one of the following is true? A. Patients should have routine ovarian cancer screening for early detection. B. Tobacco use and history of PID are risk factors for ovarian cancer, but does not outweigh the need for a genetics referral for this patient. C. A new diagnosis of ovarian cancer is more common in premenopausal than in postmenopausal women. D. Her daughter should start hormone-replacement therapy after menopause to decrease her ovarian cancer risk.

Answer: B Rationale: Most new ovarian cancer diagnoses are in patients over age 55, and hormone therapy replacement is a risk factor, not a protective factor, for ovarian cancer. There is no routine screening test for ovarian cancer, Known risk factors for ovarian cancer include smoking, nulliparity, older age at first birth, hormone replacement therapy (HRT), pelvic inflammation disease (PID), ovarian stimulation for in vitro fertilization (IVF) (in some cases), as well as genetic risk factors. Protective factors include a younger age at first pregnancy, use of OCPs, and breastfeeding. Although most ovarian cancer is not genetic, this patient meets genetic screening criteria because of the history of ovarian in the patient and breast cancer in her sister. Genetic evaluation may help determine if her daughter has hereditary risk for developing breast, ovarian, or other cancers.

6. Which one of the following is statistically more likely to be diagnosed with testicular cancer? A. 65-year-old while male with a weak urinary stream and a history of well-controlled HIV infection. B. A 32-year-old Hispanic male with a history of painless unilateral testicular swelling. C. A 25-year-old male of Pacific Islander descent with a history of recurrent herpes simplex virus-2 infection. D. A 50-year-old African American male with two first-degree relatives with a history of colorectal cancer.

Answer: B Rationale: Most testicular cancer occurs in male patients ages 20 to 43, and a painless testicular mass/swelling is a red-flag symptom for testicular cancer, and should be reported by patients to their provider if discovered on self-exam for a full diagnostic evaluation. It is less common in African American or Asian/Pacific Islander men. Other risk factors include a personal or family history of germ cell tumor (GCT), cryptorchidism, testicular dysgenesis, and Kleinfelter's syndrome.

2. The three pathognomonic features of MM are which one of the following set of examples? A. renal disease, anemia, hypocalcemia. B. monoclonal plasmacytosis, excess production of M protein, osteolytic bone lesions. C. anemia, hypocalcemia, immunodeficiency. D. low production of M protein, osteolytic bone lesions, anemia.

Answer: B Rationale: Multiple myeloma is a B-cell clonal malignancy of the plasma cells that is characterized by monoclonal plasmacytosis in the bone marrow, excessive production of M protein (myeloma-produced immunoglobulin), osteolytic bone lesions, renal disease, anemia, hypercalcemia, and immunodeficiency. Multiple myeloma is most often associated with hypercalcemia versus hypocalcemia and excessive production, and is more likely to present with elevated M protein versus low production of M protein.

7. The tumor type with the highest predilection to metastasize the central nervous system is which one of the following? A. colorectal B. melanoma C. breast D. renal cell

Answer: B Rationale: Of all tumor types, melanoma has the strongest affinity to metastasize to the central nervous system.

8. The approximate number of subjects needed for a Phase I study is which one of the following? A. 10-12 B. 20-100 C. 80-300 D. 500-1000

Answer: B Rationale: On average, 20 to 100 subjects are needed for a Phase I study. Phase I studies often include subjects with many cancer types (e.g., solid tumors), subjects with tumors refractory to standard therapy, and subjects with adequate organ function, specifically bone marrow, liver, and kidney function. Pediatric Phase I studies are conducted after a safety and toxicity evaluation in adults. Ten to twelve subjects are needed for a Phase 0 study, while 80-300 subjects are needed for a Phase II study on average. In contrast, hundreds to thousands of subjects are needed for Phase III and IV studies, on average.

9. J.T. is a 68-year-old man who has recently been diagnosed with acute myeloid leukemia (AML). Which one of the following risk factors most likely contributed to his developing the disease? A. Radiation Therapy B. Long-term exposure to benzene C. Heavy usage of alcohol D. A diet rich in red meats

Answer: B Rationale: One risk factor in developing acute myeloid leukemia (AML) is long-term exposure to benzene. Benzene is a chemical used in heavy industry, including places such as oil refineries, chemical plants, and the gasoline industry. Benzene can also be found in cigarette smoke, and in such common household items such as glue, detergent, and paint. Radiation therapy is not considered a risk factor for AML; however, exposure to high levels of radiation is seen as a risk factor. Those who have been involved in an atomic bomb attack, for instance, or been a survivor of a nuclear accident have an increased risk of developing the disease. Alcohol use and diet are not risk factors, though smoking has been linked to AML. Other risk factors include genetic disorders, such as Fanconi anemia and Down syndrome, family history of AML, as well as treatment of some chemotherapy agents.

4. J. R. is a 40-year-old female kidney transplant patient who is being treated for Merkel cell carcinoma. During an office visit, she begins showing signs of distress and asks the oncology nurse "Why me"? The nurse explains that which one of the following factors is associated with increased risk? A. Female gender B. Organ transplant C. African American descent D. Age between 35 and 50 years

Answer: B Rationale: Organ transplant is the correct answer. Transplant recipients of solid organs receive immunosuppressive therapies to prevent organ rejection, increasing their risk of Merkel cell carcinoma. Other factors associated with increased risk are male gender, white European ancestry, and age ≥ 65 years.

2. Major risk factors for endometrial cancer include increasing age, obesity, and which one of the following? A. early menopause B. hereditary nonpolyposis colorectal cancer/Lynch syndrome C. aromatase inhibitor use D. late menarche

Answer: B Rationale: Patients with HNPCC/Lynch syndrome have a 60% lifetime risk of endometrial cancer due to genetic susceptibility. Increased estrogen is associated with a higher risk of developing endometrial cancer. Modifiable sources of increased estrogen can come from obesity, a high fat diet, or diabetes. Endometrial cancer is hormonally driven, and tamoxifen can work like estrogen in the uterus and increases the risk of endometrial cancer, similarly to unopposed estrogen therapy. Aromatase inhibitors may actually decrease the risk of developing endometrial cancer. Early menarche and late menopause are risk factors for endometrial cancer as they also extend the period of time the uterus is exposed to hormonal drivers over the course of a female patient's life. Late menarche and early menopause would not be considered risk factors.

2. A patient with cancer who has undergone a craniotomy and tumor resection and the nurse caring for the patient understands that the best practice for a new baseline MRI or CT to be completed post-operatively within which one of the following time frames? A. 12 hours B. 24 hours C. 48 hours D. 72 hours

Answer: B Rationale: Points of care where neuro-imaging is indicated are pre-operatively, post-operatively, and at follow-up examinations. Preoperatively imaging is used to identify patterns of cerebral edema or location of lesions. Postoperative imaging with CT or MRI is recommended within 24 hours of surgical resection to assess residual tumor volume and establish new baseline to measure treatment effect. Follow-up examinations ordered every 3 to 4 months is the typical standard practice outside of clinical trials, unless clinically indicated otherwise.

Chapter 9 Precision Medicine 1. Which of the following information is more important in the application of precision medicine in a patient with a cholangiocarcinoma? A. 11.5 x 10.0 x 9.5 cm right hepatic lobe mass B. high positive expression of programmed death-ligand 1 (> 50%) C. tolerated adjuvant therapy with leucovorin, fluorouracil, and oxaliplatin (FOLFOX) D. alanine aminotransferase 80 U/L, aspartate aminotransferase 123 U/L, total bilirubin 2.9 mg/dL

Answer: B Rationale: Precision medicine is the use of specific information about a person's genes, proteins, and environment to prevent, diagnose, and treat disease. Tumor size, treatment history, and laboratory values may affect response but are not the primary consideration when applying precision medicine. PD-L1 expression is an example of using genomic information from the tumor and impacts treatment decisions in head and neck squamous cell, Hodgkin lymphoma, Merkel cell carcinoma, urothelial carcinomas. Targeted therapies that might be utilized in those with high PD-L1 expression include atezolizumab, avelumab, durvalumab, nivolumab, and pemrolizuma

4. For head and neck cancers, the work-up would most likely include which one of the following? A. Chest radiograph and Gallium scan B. MRI and CT C. Neck ultrasound and intravenous pyelogram D. Positron emission tomography and thyroid ultrasound

Answer: B Rationale: Radiologic studies for head and neck cancer include computed tomography (CT) and magnetic resonance imaging (MRI). Positron emission tomography (PET) with CT (PET-CT) is useful in determining specific areas for biopsy, lymph node involvement and the extent of disease to aid in treatment planning. CT is used to assist in determining the extent of the primary tumor and to identify metastasis to the cervical lymph nodes. MRI is superior to CT in staging nasopharyngeal primaries. PET is ordered to document metastatic spread of tumor cells. When providers order diagnostic radiologic studies, they do not order only chest X-ray or ultrasound. Intravenous Pyelogram is used to evaluate kidneys, ureters, and bladder. A gallium scan is useful in evaluating patients with potential lymphoma, infection, osteomyelitis, or pulmonary problems.

14. Which of the following is a recommended screening for pancreatic cancer? A. Ultrasound every 6 months is recommended for high-risk individuals B. Routine screening is not recommended for individuals who are not presenting symptoms C. EUS or MRI/magnetic resonance cholangiopancreatography (MRCP) D. No screening methods are currently identified

Answer: B Rationale: Routine screening for pancreatic cancer is not recommended for individuals who are not presenting symptoms. EUS or MRI/magnetic resonance cholangiopancreatography (MRCP), however, may be used as a screening technique for individuals with genetic mutations such as HBOC, Lynch syndrome, or PJS. Ultrasound every 6 months is recommended as screening for high-risk individuals of developing hepatocellular cancer, which include patients with all types of cirrhosis and hepatitis B virus (HBV) carriers without cirrhosis. No screening methods have yet to be identified for cholangiocarcinomas - a rare cancer that encompasses all tumors originating from the epithelium of the bile duct.

10. Signs and symptoms of head and neck cancer include which one of the following? A. a temperature >100°F accompanied by a sore throat B. a lump or sore that does not heal in the mouth or lip C. bilateral ear pain with hearing loss D. episodic hoarseness that resolves in 1 week

Answer: B Rationale: Signs and symptoms of head and neck cancer include a lump or sore that does not heal in the mouth, lip, throat or jaw; a sore throat that does not go away; a change or hoarseness in the voice that does not resolve; difficulty chewing, swallowing, or moving the jaw or tongue; and a pain in one ear without hearing loss. A temperature of > 100°F does not suggest a sign or symptom of head and neck cancer.

2. F.R. is a 52-year-old male who arrives on the oncology unit with a diagnosis of extensive small-cell carcinoma of the lung. The nurse assigned to the patient is aware that this type of lung cancer is which one of the following statements? A. is slow growing and less likely to metastasize B. has a more aggressive course C. has a better prognosis than the other forms of lung cancer D. has multiple surgical options

Answer: B Rationale: Small cell lung cancer is diagnosed in 0-15% of lung cancers and has a more aggressive, rapidly growing course compared to the other carcinoid types. Since it is a rapidly growing disease, small cell lung cancer is likely to metastasize. Patients with limited disease have a median survival of 15-20 months, and are often treated with chemotherapy in combination with radiation therapy, while patients do not have multiple options for surgery. In fact, surgery is not an option. Small cell lung cancer is associated with a poor prognosis with overall 5-year survival at 5% to 10% and when untreated median survival 2 to 4 months, so it does not have a better prognosis than other forms of lung cancer.

9. Grading for prostate cancer is based on the Gleason Score, which is determined by results from which one of the following? A. imaging tests using MRI or CT B. tissue specimen examination C. blood tests for PSA levels D. bone marrow aspiration

Answer: B Rationale: The Gleason Score is based on microscopic examination of the prostate tumor tissue specimen. The pathologist determines the most common cell grade seen in the largest portion of the specimen (the primary cell grade) and in the second largest portion (the secondary cell grade). The two grades are then added together to determine the Gleason score. This score provides information about the aggressiveness of the disease in the prostate and serves as a guide for treatment strategies. Imaging tests using MRI or CT provide information about the extent of the disease but are not part of the process for determining the Gleason score, which is based on characteristics of the malignant tumor cells. PSA levels are not used for computing the Gleason Score but may be useful as a marker for disease progression. Bone marrow aspiration is not used as a screening or diagnostic measure for prostate cancer.

9. Which of the following is a definition of gene deletion? A. Heritable change that does not alter the DNA sequence but changes gene expression. B. Loss of all or part of a gene found in cancer and other genetic diseases. C. Increase in the copies of a protein made from a gene that may play a role in cancer development. D. Increase in the number of copies of a gene that may cause cancer cell growth or resistance to anticancer drugs.

Answer: B Rationale: The correct answer is B. Gene deletion is defined as the loss of all or part of a gene found in cancer and other genetic diseases is defined. Answer A is epigenetic alteration, which is defined as a heritable change that does not alter the DNA sequence but changes gene expression. Gene overexpression (answer C) is the increase in the copies of a protein made from a gene that may play a role in cancer development. Answer D is gene amplification, which is defined as the increase in the number of copies of a gene that may cause cancer cell growth or resistance to anticancer drugs.

10. Which is the following is an example of pharmacokinetics? A. Examination of how a drug will affect an individual patient B. Examination of how an individual patient will affect a drug C. Study of how a patient's genomes affect responses to certain types of medications D. Study of heredity and the variation of inherited characteristics

Answer: B Rationale: The correct answer is B. Pharmacokinetics examines how the individual will affect the drug. This is contrary to pharmacodynamics, which is how the drug will affect the individual (Answer A). Pharmacogenomics (Answer C) is the study of how a patient's genomes affect responses to medications. And genetics is the study of heredity and the variation of inherited characteristics.

11. Which one of the following descriptions defines the oropharynx? A. Extends from the lips to the hard palate above and the circumvallate papillae below, and structures include lips, buccal mucosa, floor of the mouth, and upper and lower alveoli. B. Located below the base of the skull and behind the nasal cavity and continuous with the posterior pharyngeal wall. C. Extends from the circumvallate papillae below and hard palate above to the level of the hyoid bone. D. Extends from the epiglottis to the cricoid cartilage; protected by the thyroid cartilage, which encases it.

Answer: B Rationale: The oropharynx extends from the circumvallate papillae below and hard palate above to the level of the hyoid bone. Structures of the oropharynx include the base of the tongue (posterior one third), soft palate, the tonsils, and posterior pharyngeal wall. The oral cavity extends from the lips to the hard palate above and the circumvallate papillae below, with structures including the lips, buccal mucosa, floor of the mouth, and upper and lower alveoli. The nasopharynx is located below the base of the skull and behind the nasal cavity and continuous with the posterior pharyngeal wall. Finally, the larynx extends from the epiglottis to the cricoid cartilage and protected by the thyroid cartilage.

2. R.K.is a male, 46-year-old patient with Stage II diffuse large B-cell lymphoma, who has been admitted for treatment. The oncology nurse caring for him knows that the standard treatment for a patient with this diagnosis is which one of the following? A. autologous peripheral blood stem cell transplant B. rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone C. salvage radiation therapy with 6000 cGy D. ifosfamide, carboplatin, etoposide, prednisone

Answer: B Rationale: The patient has Stage II diffuse large-B cell lymphoma. Diffuse large-B cell lymphoma is the most common type of non-Hodgkin lymphoma (NHL). Standard treatment options include chemotherapy with or without radiation therapy, and RCHOP. Autologous peripheral blood stem cell transplant is indicated for patients with recurrent NHL. Salvage radiation therapy is not a treatment plan for patients with NHL. Ifosfamide, carboplatin, etoposide (ICE) is a second-line regimen for patients who have relapsed/refractory Hodgkin's Lymphoma.

7. D.P. is a 48-year-old woman who was treated 2 years ago for HER2-positive breast cancer with an anthracycline and taxane, as well as trastuzumab for 1 year. She calls the clinic stating she is short of breath. She is scheduled for a follow-up visit immediately. Her oncology team is concerned about which one of the following? A. brain and liver metastasis B. lung metastasis and cardiac failure C. liver and lung metastasis D. brain and lung metastasis

Answer: B Rationale: The patient has received trastuzumab, which can lead to a decreased left ejection fraction or pulmonary problems. An anthracycline can also lead to cardiac toxicity. Breast cancer often metastasizes to the lung. Breast cancer also metastasizes to the brain and liver, but her symptoms are not suggestive of metastasis to these organs.

6. An oncology nurse is reviewing a patient with lung cancer's pathology report and notes that the patient has the presence of the KRAS mutation. She knows that having this mutation: A. has a very good response to tyrosine kinase inhibitors. B. determines a poorer survival rate than those without it. C. is associated with response to monoclonal antibodies. D. allows the patient to only take oral medications as part of their treatment.

Answer: B Rationale: The presence of the KRAS mutation is associated with tyrosine kinase inhibitors (TKI) resistance and overall poor survival compared to patients without the KRAS mutation. Having the KRAS mutation and the use of monoclonal antibodies has shown no response in patients who received monoclonal antibodies and in patients who harbored the KRAS mutation, and the use of oral medications alone in therapy has not shown any effect on the KRAS mutation.

5. The individual with primary responsibility to ensure the ethical conduct of the research study is which one of the following? A. study coordinator B. principal investigator C. statistician D. data manager

Answer: B Rationale: The principal investigator ensures the ethical conduct of the research study. The study coordinator, statisticians, and data managers are all important members of the research team, but not responsible for the research study as a whole. The responsibilities of these other research members may vary from study to study.

17. The small arm of the chromosome is labeled as A. o B. p C. q D. s

Answer: B Rationale: The small arm is known as the petite arm and is labeled as "p". The long arm is labeled as "q" because "q" comes after "p" in the alphabet. There is no "o" or "s" arm.

7. T. C. is a 35-year-old son of a patient who has been diagnosed with bladder cancer. During a recent visit, he asks the nurse for advice on which behaviors he should adopt to help him reduce the risk of him becoming diagnosed with cancer, like his father. The nurse explains that factors associated with increased risk include which one of the following? A. weight loss B. tobacco use C. excessive fluid intake D. diet low in processed meats

Answer: B Rationale: Tobacco use is the most significant risk factor, accounting for 50% to 66% of all bladder tumors in men and 25% in women. Weight loss is not a risk factor; rather a high BMI may increase risk, and contribute to risk of disease recurrence. Excessive fluid intake does not increase bladder cancer risk but not drinking enough fluids is reported to be a risk factor. Consuming a diet low in processed meats may be somewhat protective for bladder cancer.

6. C. M. is a 47-year-old female patient who has been diagnosed with urothelial carcinoma of the bladder. The nurse educating the patient and her family about this type of bladder cancer explains that urothelial carcinoma of the bladder is: A. the least common type of bladder cancer. B. responsible for most cases of bladder cancer. C. most likely to be invasive at diagnosis. D. associated with changes to chromosome 9.

Answer: B Rationale: Urothelial carcinoma of the bladder is the most common type of bladder cancer and comprises about 95% of bladder tumors. In 70% to 80% of cases, this type of tumor is generally diagnosed before it has become invasive and invaded the muscle wall of the bladder. Urothelial tumors are not associated with changes to chromosome 9, which are associated with papillary bladder cancers.

13. Mr. H. and his wife are distressed with his recent diagnosis of testicular cancer. During the course of the assessment, it becomes clear to his oncology nurse that some of this distress is related to fertility concerns. His nurse discusses sperm banking with the couple. The nurse explains that sperm banking should be completed: A. before surgery. B. before chemotherapy. C. after surgery. D. after chemotherapy.

Answer: B Sperm banking may be done before or after surgery, but ideally before any radiation therapy or chemotherapy since these treatments may have an adverse effect on male fertility.

15. Risk factors for central nervous system tumors can be known intrinsic, known situational, known extrinsic, and genetic/inherited risk. Of the following risk factors, which one is a known extrinsic risk factor? A. Immunocompromised, including HIV/AIDS, immunosuppressive medical therapies, and congenital immunodeficiency. B. Exposure to pesticides, vinyl chloride and petrochemicals. C. Ionizing radiation (IR), with a causal relationship between therapeutic irradiation of doses > 2500 cGy and development of brain tumors. D. Race/ethnicity, with Caucasian northern European most common and meningioma more common in African American populations.

Answer: C Ionizing radiation (IR) is a known extrinsic risk factor. According to various sources, there is a causal relationship between therapeutic irradiation of doses > 2500 cGy and development of brain tumors; risk higher for nerve sheath tumors and meningiomas than gliomas. Being immunocompromised, including having a diagnosis of HIV/AIDS, taking immunosuppressive medical therapies, and having a congenital immunodeficiency are all examples of situational risk factors. Exposure to pesticides, vinyl chloride, petrochemicals, electromagnetic fields, inks and solvents, dietary N-nitroso compounds, long-term use of black or brown hair dyes, cell phones, aspartame, and certain viral exposures are unknown risk factors and currently under investigation. Race/ethnicity is an intrinsic risk factor. The most at risk are Caucasian with northern European descent, while meningioma is more common in African American populations.

12. A germline mutation occurs in the gametes and: A. is present only in first generation. B. is present in non-reproductive cells. C. can include a de novo mutation. D. includes every cell in the body.

Answer: C Rationale: A de novo mutation is change in a gene and is present for the first time in one family member due to mutation in a germ cell (egg or sperm) of one of the parents or in the fertilized egg. A is incorrect as a germline mutation is passed from generation to generation. B is incorrect as germline mutations are present in the reproductive cells (the eggs and sperm). D is incorrect as it only occurs in the gametes: eggs and sperm.

7. Which one of the following is a key association and cause of cancer? A. Three servings of fresh fruits and vegetables weekly B. White meat in daily diet C. Too much fiber in daily diet D. Sun exposure and indoor tanning parlors

Answer: C Rationale: A history of sunburns and tanning parlor use is a key association and cause of cancer. Too much fiber in a person's daily diet is not identified as key association and cause of cancer rather lack of fiber is identified as a cause for cancer. Other key association and causes of cancer include lack of exercise and daily intake of processed red meat. Five to nine servings of fruits and vegetables are recommended daily. Lack or limited intake of fruits and vegetables is a key association and cause of cancer.

4. T. K. is a 43-year-old male patient. During a physical assessment, the nurse notes a palpable mass in the area of a patient's fibia. A key part of assessment and documentation would be to include a(n): A. needle aspiration B. incision and drainage C. comparison to the unaffected side D. evaluation of complete blood count results

Answer: C Rationale: A possible bone or soft tissue mass may or may not be visible or palpable. The mass may be firm, nontender, and warm. Its size should be compared bilaterally to the other fibia. This type of mass is not described as pus-filed or pock-marked. Anemia is a condition related to the patient's blood, not the bone or soft tissue mass.

5. S.D. is a 49-year-old man who has come to the clinic for treatment. An oncology nurse is assessing this patient's past medical history and discovers that the patient has a history of Helicobacter pylori bacterial infection. The nurse reports this finding, as this is a significant risk factor for the development of which one of the following? A. breast cancer B. cancer of the distal colon C. mucosa-associated lymphoid tissue (MALT) lymphoma D. Burkitt lymphoma

Answer: C Rationale: A risk factor for the development of MALT lymphoma of the stomach is the bacterial infection Helicobacter pylori infection (H.pylori). Having H.pylori does not put a patient at risk for developing breast cancer or cancer of the distal colon, but it does increase the risk of developing gastric cancer and should be treated. A risk factor for development of Burkitt lymphoma is EBV infection.

5. The oncology nurse is teaching K.T, a 40-year-old female patient, how to recognize skin signs that could indicate a need for melanoma assessment by a specialist. The nurse should instruct the patient to report the sighting of a mole showing signs of which one of the following? A. regular border B. symmetrical shape C. tendency to bleed D. uniform brown color

Answer: C Rationale: A tendency to bleed is the correct answer. Moles that bleed or itch, or demonstrate changes in shape, size, or color are concerning and require specialized evaluation. Normal moles have a symmetrical shape, regular borders, and are uniformly one color. The ABCDE rule can help reinforce characteristics of melanoma. A refers to asymmetry. B refers to border irregularity or faded borders. C refers to color irregularities or having multiple colors. D refers to diameter more than 5 mm. E refers to evolving

2. The three stages of HIV are which one of the following? (choose the correct progression of disease): A. chronic/progressive disease, acquired immune deficiency syndrome (AIDS), acute infection B. acute infection, AIDS, chronic/progressive infection C. acute infection, chronic/progressive infection, AIDS D. chronic/progressive disease/acute infection

Answer: C Rationale: Acute infection occurs, then proceeds to a chronic/progressive infection before manifesting into AIDS. During the chronic/progressive infection stage, qualitative and quantitative T4-lymphocyte dysfunction occurs, with resultant defects in both cellular and humoral immunity as immunoregulatory function of T4 cells is gradually impaired. The order in answer A of chronic/progressive disease, AIDS, and acute infection is incorrect since acute infection would come before either of the two steps. B is also incorrect. While acute infection occurs first in the progression of the disease, contracting AIDS is the final step and does not come prior to chronic/progress infection. Finally, D is also incorrect, and also incomplete, as the answer omits the final stage of AIDS.

4. An approved agent that could be utilized for the primary prevention of breast cancer in high-risk post- menopausal women with breast cancer is the use of which one of the following? A. retinoids B. metformin C. aromatase inhibitors D. Cox-2 inhibitors

Answer: C Rationale: Aromatase inhibitors can prevent a new breast cancer from developing and are appropriate to utilize in women who are known to be postmenopausal. Premenopausal and postmenopausal women can also consider utilizing tamoxifen to reduce the risk of developing breast cancer. Metformin, retinoids, and cox-2 inhibitors are under investigation to determine if they are effective for the primary prevention of breast cancer.

5. What type of breast cancer is suggestive of poor prognosis? A. ER-positive, PR-positive invasive ductal carcinoma B. ER-positive, PR-positive invasive lobular carcinoma C. ER-negative, PR-negative, Her-2/Neu-negative breast cancer D. T4 tumor between 5 and 10 cm with no lymph nodes positive

Answer: C Rationale: Basal cancers, known as triple negative breast cancer, tend to have a worse prognosis. Luminal A tumors have a high ER/PR expression and tend to respond well to endocrine therapy and are often associated with a better prognosis. The prognosis of lobular carcinoma is similar to that of ductal carcinoma. A poorer prognosis is associated with lymph node involvement

13. Based on statistics reported by the National Cancer Institute (NCI) in 2018, between 1975 and 2010, childhood osteosarcoma mortality decreased by more than which one of Answer: C Rationale: Based on statistics reported by the National Cancer Institute (NCI) in 2018, between 1975 and 2010, childhood osteosarcoma mortality decreased by more than 50%. In adolescents ages 15 to 19 years old, the 5-year survival rate was reported to have increased 56% to approximately 66%, so those percentage values do not equal the decrease in mortality. Forty percent is incorrect.the following percentages? A. 56 percent B. 66 percent C. 50 percent D. 40 percent

Answer: C Rationale: Based on statistics reported by the National Cancer Institute (NCI) in 2018, between 1975 and 2010, childhood osteosarcoma mortality decreased by more than 50%. In adolescents ages 15 to 19 years old, the 5-year survival rate was reported to have increased 56% to approximately 66%, so those percentage values do not equal the decrease in mortality. Forty percent is incorrect.

3. The diagnosis of multiple myeloma is confirmed by: A. bone scan B. complete blood count C. bone marrow biopsy D. renal ultrasound

Answer: C Rationale: Bone marrow biopsy is the confirmatory test for establishing the diagnosis of multiple myeloma, which demonstrates the presence of more than 10% clonal plasma cells. Additional tests that might be used to assess the extent of multiple myeloma include serum protein immunoelectrophoresis, urine protein immunoelectrophoresis, serum lactate dehydrogenase, and urinary light chain M proteins (Bence Jones proteins). Multiple myeloma-related organ dysfunction is also evaluated with laboratory assessment for hypercalcemia, renal insufficiency, and anemia, as well as lytic bone lesions. While a bone scan might identify a lytic lesion, it is not diagnostic for multiple myeloma. A renal ultrasound can determine some abnormalities in the kidneys but does not assess for renal insufficiency. A complete blood count will demonstrate anemia, but it is not specific for multiple myeloma.

3. A.R. is a 60-year-old woman who arrives at an office visit complaining of bone pain. She explains to her nurse how she is feeling and what the sensation is like. Typically, patients describe bone pain as which one of the following? A. prickly B. intermittent C. aching D. sharp

Answer: C Rationale: Bone pain is described as dull and aching, increasing at night and increasing over time. Prickly and sharp pain describes pain that involves the nervous system. Bone pain is steady pain, not intermittent pain.

6. Chronic lymphocytic leukemia accounts for 25% of all diagnosed leukemias. Which one of the following statements is also true regarding chronic lymphocytic leukemia? A. Chronic lymphocytic leukemia is the second most frequent form of leukemia. B. Chronic lymphocytic leukemia is more frequently seen in those of Hispanic and Asian than those of Caucasian descent. C. Chronic lymphocytic leukemia is most commonly diagnosed at 60 years of age, with less than 15% diagnosed under age 50 years. D. Chronic lymphocytic leukemia is a leukemia that originates from immature B lymphocytes.

Answer: C Rationale: CLL is a diagnosis that is diagnosed at a median age of 60 years old and less than 15% are diagnosed under the age of 50. CLL is the most frequent form of leukemia. CLL is more frequently seen in a Caucasian population than a Hispanic or Asian population. CLL originates from mature B lymphocytes.

6. The use of targeted therapies is common within oncology practice and involves the use of genetic and genomic information of the cancer tissue to guide selection of an appropriate targeted drug therapy. One of the benefits of using targeted therapies is: A. less severe adverse reactions. B. not classified as hazardous drugs. C. spare normal cells. D. only available in oral formulation.

Answer: C Rationale: Clinically relevant biomarkers are associated with specific cancers; ideal targets are present in cancer cells but not in normal cells. Targeted therapy has adverse reactions, albeit different from traditional chemotherapy. Targeted therapies can be classified as hazardous drugs, and can be delivered orally (small molecule drugs) or parenterally (Monoclonal Abs).

8. Diagnostic measures utilized in the diagnosis of breast cancer include which one of the following? A. mammography B. breast MRI C. core needle biopsy D. whole-breast ultrasound

Answer: C Rationale: Diagnostic modalities for breast cancer include core needle biopsy, stereotactic vacuum-assisted breast biopsy, fine-needle aspiration (FNA), incisional biopsy, or excisional biopsy. Imaging with mammography, breast MRI, or breast ultrasound may be used to localize the site to be biopsied.

4. The use of ER/PR/Her-2/Neu status to guide decisions on the use of adjuvant systemic chemotherapy is an example of: A. use of a cancer-risk assessment tool to confirm suspected familial cancer syndromes. B. dose determination based on genomics. C. use of biomarkers to guide treatment decisions. D. use of testing to determine eligibility for a clinical trial.

Answer: C Rationale: ER/PR/Her-2 Neu are examples of biomarkers used to guide treatment decisions. Germline genetic testing might confirm the presence of a hereditary cancer predisposition syndrome. ER/PR/Her2 Neu status does not alter the dose of the drug but it might alter the choice of agent. Adjuvant chemotherapy decisions might also be based on tools that assess a combination of genes on a tumor to determine the potential efficacy of chemotherapy (e.g. Mammaprint, Endopredict, or Oncotype). Er/PR/Her2Neu status might be one criteria utilized to determine if a patient is eligible for a clinical trial but it will not be the sole criteria.

6. A patient with a progressive malignant brain tumor reports to the oncology nursing caring for him that he is having symptoms of hyperglycemia, myopathy, lymphopenia, and osteoporosis. The nurse understands these symptoms are most likely related to which one of the following? A. bone resorption inhibitors B. anticonvulsants C. corticosteroids D. immunosuppressants

Answer: C Rationale: Each of these drug classes may have one or more of these side effects, but corticosteroids are the only one that has all these risks.

10. Which one of the following is a treatment for early-stage (IA1-IB1) cervical cancer? A. Radical hysterectomy, lymph node evaluation B. Definitive chemoradiation (with or without ovarian transposition if premenopausal), possibly neoadjuvant chemotherapy followed by resection C. Fertility sparing, including conization with cold knife or LEEP procedure, lymph node evaluation if lymphovascular space invasion (LVSI) is present, radical trachelectomy D. Primary treatment followed by observation, external beam radiation therapy (EBRT), and/or adjuvant chemotherapy

Answer: C Rationale: Fertility sparing, including conization with cold knife or LEEP procedure, lymph node evaluation if lymphovascular space invasion (LVSI) is present, radical trachelectomy is a treatment for early-stage (IA1-IB1) cervical cancer. Radical hysterectomy and lymph node evaluation is treatment for select IIA1 disease. For IB2, IIA2, or greater nonsurgical candidates, the recommended treatment is definitive chemoradiation (with or without ovarian transposition if premenopausal), and possibly neoadjuvant chemotherapy followed by resection. Primary treatment followed by observation, external beam radiation therapy (EBRT), and/or adjuvant chemotherapy is a treatment for advanced disease.

11. L.J. is a 47-year-old female patient with metastatic cervical cancer. Which one of the following would her nurse know to be a treatment for metastatic cervical cancer? A. Simple or modified radical hysterectomy with or without lymph node evaluation B. External beam radiation therapy (EBRT) and neoadjuvant chemotherapy C. Radiation therapy with or without chemotherapy, palliative systemic agents, and supportive care D. Radiation therapy, systemic therapy, local ablation, and surgical resection

Answer: C Rationale: For treatment of metastatic cervical cancer, the recommendation is radiation therapy with or without chemotherapy, palliative systemic agents, and best supportive care. Simple or modified radical hysterectomy with or without lymph node evaluation is a non-fertility sparing option for early-stage disease (IA1-IB1). External beam radiation therapy (EBRT) and neoadjuvant chemotherapy is incorrect. EBRT is used for advanced stage cancers but not in conjunction with neoadjuvant chemotherapy. Neoadjuvant chemotherapy followed by resection, along with definitive chemoradiation (with or without ovarian transposition if premenopausal), is used in IB2, IIA2, or greater nonsurgical candidates: radiation therapy, systemic therapy, local ablation, and surgical resection are treatments for recurrent disease.

11. Which one of the following is a significant risk factor for adenocarcinoma of the esophagus? A. Smoking B. Alcohol C. Gastroesophageal reflux disease D. Somatic BRCA1/2 mutation

Answer: C Rationale: Gastroesophageal reflux disease (GERD) is a risk factor for adenocarcinoma of the esophagus. A somatic BRCA1/2 mutation is a potential mutation found in a tumor cell and is not a risk factor. Smoking and alcohol use are risk factors for squamous cell carcinoma of esophagus, not adenocarcinoma.

4. A new oncology nurse asks how to determine if a cell is somatic or germline. You explain that: A. Germline cells will have single nucleotide polymorphisms (SNPs) associated with a mutation. B. A somatic cell acquires mutations during the monthly reproductive cycle of the body. C. Germline mutations occur in reproductive cells of a person with an inherited cancer predisposition. D. Somatic cells accumulate mutations prior to conception while in utero.

Answer: C Rationale: Germline mutations occur in the reproductive cells of a person with an inherited predisposition to cancer. A is incorrect because single nucleotide polymorphism (SNPs) occur in both germline or somatic cells. A SNP is a change in a nucleotide of a gene causing variation in the DNA sequence that affects 1% of population. B is incorrect as both males and females develop mutations in their somatic cells over a lifetime. Only females have a monthly reproductive cycle. D is incorrect as somatic mutations occur in body cells (except the gametes) after conception and are acquired over a lifetime.

6. A nurse is caring for a 29-year-old female patient who was recently diagnosed with AIDS. Her CD4 count is 293, and she is on active antiretroviral therapy. Based on the information provided, the nurse would educate the patient on the fact that she is at increased risk for developing which one of the following types of cancer? A. lung cancer B. acute myeloid leukemia C. cervical cancer D. kidney cancer

Answer: C Rationale: HIV-infected women are at an increased risk for cervical dysplasia that rapidly progresses to cervical cancer. AIDS-defining cancers include non-Hodgkin lymphoma (NHL), Burkitt lymphoma, Kaposi sarcoma, and cervical cancer. B-cell lymphoma is the most frequently diagnosed AIDS-defining malignancy. AIDS-defining malignancies are more common shortly after initiation of active retroviral therapy, particularly among patients with low CD4 counts. Lung, acute myeloid leukemia, and kidney cancer are all non-AIDS defining cancers.

13. Which of the following may be a psychological consequence to the patient that receives genetic testing results that reveal substantially increased risk for developing cancer or another primary lesion? A. Depression yet a sense of relief B. Transmitter guilt C. Heightened anxiety D. Survivor guilt

Answer: C Rationale: Heightened anxiety may result when patients learn that they are at a substantially increased risk for developing cancer or another primary lesion. A is incorrect as, although there can be depression, a sense of relief has not been reported; in fact they experience more anxiety. B is incorrect as this relates to family members versus the patient as it occurs when family members pass on the genetic mutation to one of their offspring. D is incorrect as you see this type of guilt in persons who have not inherited the genetic mutation present in other close family members.

10. J.J. is a 54-year-old HIV-infected male patient who has been admitted for treatment of PCP pneumonia with intravenous Bactrim. On Day 2 of his admission, the patient develops altered mental status, fever, shortness of breath and leukocytosis. His nurse anticipates the patient is experiencing signs and symptoms of which one of the following? A. worsening PCP pneumonia. B. anaphylactic reaction to Bactrim. C. immune reconstitution syndrome. D. superimposing infection.

Answer: C Rationale: Immune reconstitution syndrome occurs with severe inflammatory or infectious reactions, as well as with initial cART therapy. Immune reconstitution syndrome has occurred with toxoplasmosis, pneumocystis, other opportunistic infections in HIV disease, and EBV reactivation. Immune reconstitution syndrome has also been linked to rituximab administration. Anaphlaxis to Bactrim would likely occur with the first dose so the patient would not be experiencing symptoms such as altered mental status, fevers, and shortening of breath on Day 2. Superimposing infection or worsening PCP pneumonia would not necessarily be accompanied by altered mental status, so A is incorrect as well.

11. Potential complications after treatment with radio- active seed placement into the prostate include which one of the following? A. decreased libido B. constipation C. impotence D. anemia

Answer: C Rationale: Impotence is the correct answer. Some form of impotence has been seen in 6% to 61% of men following brachytherapy to treat prostate cancer. Diarrhea, rather than constipation, is associated with both radiation therapy and brachytherapy. Anemia is not a side effect of brachytherapy because little bone marrow is exposed to radiation with this treatment.

3. T.F. is a 54-year-old female patient who reports episodes of hematuria. The nurse anticipates which one of these diagnostic tests to determine etiology? A. Colonoscopy B. Kidney biopsy C. Intravenous pyelogram D. Blood chemistries

Answer: C Rationale: Intravenous pyelogram is the correct answer. This diagnostic test is commonly used to evaluate patients presenting with hematuria. Colonoscopy visualizes the colon, and is not used to determine the cause of hematuria. The kidney is not biopsied to determine the cause of hematuria, and blood chemistry results would not be diagnostic for hematuria.

6. A patient is being seen in the high-risk cancer clinic because there are features suggestive of a risk for hereditary cancer. These features could include: A. passage of a trait to future generations on only one allele of a chromosome. B. no known germline deleterious mutation in a cancer susceptibility gene. C. autosomal dominant designation of a cancer. D. a unique variety of cancer types in multiple generations.

Answer: C Rationale: Most hereditary cancer syndromes are inherited in an autosomal dominant fashion. A is incorrect because in most cases the altered gene is passed from one side of the family. B is incorrect as there are deleterious germline mutations in cancer susceptibility genes that are suggestive of risk for hereditary cancer. D is incorrect as cancer types are similar in multiple generations, usually from one side of the family, with a risk for hereditary cancer.

9. HIV-infected patients diagnosed with primary CNS lymphoma have which one of the following? A. extensive bone marrow involvement B. a normal CD4 count C. a 20% chance of ocular involvement D. a concurrent CMV infection

Answer: C Rationale: Ocular involvement occurs in 20% of patients diagnosed with primary central nervous system lymphoma, and commonly have multifocal lesions. HIV-infected patients do not have extensive bone marrow involvement, nor do they have other organ/tissue involvement. This patient population also has a low CD4 count and do not generally have concurrent CMV but EBV infection.

4. The mother of a child diagnosed with a primary central nervous system tumor asks the nurse about her child's chances of survival. The nurse responds to the mother with an understanding that the 5-year survival rate for children and teens diagnosed with a primary central nervous system tumor is which one of the following? A. 25% B. 50% C. 75% D. 90%

Answer: C Rationale: Of children and teens diagnosed with a central nervous system tumor, about 75% will be alive more than 5 years after the initial diagnosis. This is important for the oncology nurse to anticipate because of the substantial survivorship issues that these children, teens, and parents must endure.

9. A nurse on an oncology unit is administering Pembrolizumab to a patient with lung cancer. The nurse understands that this medication: A. blocks enzymes to prevent cancer cells from growing and dividing. B. is a second-line therapy for patients with advanced non-small-cell lung cancer. C. is an immune-checkpoint inhibitor. D. harbors molecules which break down cancer cells.

Answer: C Rationale: Pembrolizumab, along with Nivolumab and Atezolimab, are anti-PD-1 human monoclonal antibodies and immune checkpoint inhibitors approved for the first-line treatment of NSCLC. Tyrosine kinase inhibitors are EGRF-targeted therapies that block cancer cells from growing and dividing. Erlotinib is first-line therapy for individuals with advanced, recurrent, or metastatic non-squamous NSCLC. Pemrolizumab does not harbor molecules which break down cancer cells. Immune-checkpoint inhibitors are drugs that block specific proteins involved in downregulation of immune response in cancer cells.

9. The standard treatment for most patients with newly diagnosed endometrial cancer is which one of the following? A. fertility sparing whenever possible B. oral hormonal therapy for 10 years for estrogen suppression C. upfront hysterectomy and bilateral salpingo- oophorectomy D. D&C followed by close observation for endometrial thickening

Answer: C Rationale: Per National Comprehensive Cancer Network (NCCN) guidelines, the standard of care for endometrial cancer is usually an upfront TH/BSO, which may or may not be followed by adjuvant treatment. Fertility sparing surgery is not usually recommended and is considered as a treatment only in rare cases with genetic counseling, continuous progestin-based suppression, and hysterectomy after childbearing, or on progression of disease. Hormone therapy is generally reserved for patients who are not surgical candidates, and is continued until progression. Assessing for endometrial thickening, or preforming a D

8. After amputation, the patient may experience phantom limb pain: A. for 1-2 weeks after surgery. B. postoperatively, starting 8 weeks or more after surgery. C. chronically. D. intermittently when standing.

Answer: C Rationale: Phantom limb pain or sensation can occur one to four weeks postoperatively. This type of pain can resolve in a few months or can be chronic. The patient may describe phantom limb pain as itching, pressure, tingling, severe cramping, throbbing, and/or a burning pain. Phantom limb pain occurs over a period of time and not just when the patient intermittently stands.

Chapter 7 Cacinogenesis 1. L.S. is a 49-year-old female with pancreatic cancer. During the course of her diagnosis and treatment, L.S. asks the oncology nurses in her care about the cause of her cancer. The oncology nurse responds to the question from L.S. with the understanding that the gene mutation frequently affecting this condition is caused by which one of the following: A. a missense gene mutation B. a chromosome translocation C. a proto-oncogene mutation D. an insertion mutation

Answer: C Rationale: Proto-oncogenes that are mutated, such as Ras, can enable a cancer cell to be self-sufficient in growth, and are common in pancreatic and colorectal cancers. In chromosome translocations, one chromosome moves to another as the cell divides, thereby activating an oncogene, such as occurs in CML where the BCR gene on chromosome 9 is fused to the Abl gene on chromosome 22, making a protein called tyrosine kinase, which proliferates myeloid cells. Missense mutation changes a DNA base pair that results in the substitution of one amino acid for another in the protein made by a gene and is typically the cause of sickle cell disease. An insertion mutation is the addition of one or more nucleotide base pairs into a DNA sequence, such as occurs in Huntington's disease or fragile X syndrome.

5. Which one of the following viruses is most commonly associated with anal cancer? A. hepatitis B virus B. Epstein-Barr virus C. Human papillomavirus (HPV) D. Human herpes virus (HHV-8)

Answer: C Rationale: Risk factors for anal cancer include human papillomavirus infection (HPV) infections, human immunodeficiency virus (HIV) infection, anal sex, and lowered immunity. Hepatitis B (HBV) is associated with liver cancer. EBV is associated with nasopharyngeal cancer. Human herpes virus (HHV-8) is associated with Kaposi sarcoma.

3. T.C. is a 44-year-old female, who is a newly diagnosed patient with lung cancer. Her nurse, working in an outpatient oncology clinic, reviews her chart prior to the patient visit. She is trying to determine the patient's highest risk for developing lung cancer. Which of one of the following actions would give her the best information regarding the patient's risk? A. questions the patient about the age when they first started smoking B. assesses the frequency of cigarettes smoked during a day C. assesses the number of packs of cigarettes smoked daily and years of smoking D. reviews the family history of smoking and passive smoke exposure

Answer: C Rationale: Risk of lung cancer increases with the number of years the individual has spent smoking and number of cigarettes smoked per day. To quantify tobacco exposure, the number of packs of cigarettes per day is multiplied by the number of years smoked to obtain pack history. Assessing the age when the patient began smoking, the frequency of smoking, and family history of the patient does not quantify the patient's risk of smoking. Pack years must be calculated to have a more complete risk assessment for developing lung cancer.

6. J.M. is a 67-year-old male patient, with a newly diagnosed, symptomatic multiple myeloma. The patient has started on a triple regimen with bortezomib, lenalidomide, and low dose dexamethasone. Which one of the following is a key nursing consideration for educating the patient on chemotherapy? A. Intravenous aprepitant on day 1 of each cycle B. Allopurinol prophylaxis C. Acyclovir prophylaxis D. Intravenous fluid hydration three times a week

Answer: C Rationale: Shingle prophylaxis is indicated during proteasome inhibitor-based therapy with bortezomib, carfilzomib, or ixazomib secondary to the increased risk during treatment. Shingle prophylaxis includes daily acyclovir or valacyclovir. Although anti-emetics may be administered to patients on this regimen, aprepitant is not routinely used. Although there is a risk for tumor lysis syndrome and hydration is important in the overall care of the patient, they are not standard nursing interventions in caring for persons on this regimen.

9. A primary nursing concern for a patient who has undergone a supraglottic laryngectomy is the risk for which one of the following? A. fall B. dehydration C. aspiration D. somnolence

Answer: C Rationale: Since the structures above the false vocal cords are resected during a supraglottic laryngectomy, the patient is at risk for aspiration until the patient learns swallowing techniques to protect the airway. Post-operative care of any patient includes risk of falling, maintaining hydration, and somnolence, but these are not the primary concern of nurses caring for postop supraglottic laryngectomy

4. A "3 3" Phase I trial to determine maximum tolerated dose is an example of which type of clinical trial design? A. Factorial B. Parallel C. Adaptive D. Basket

Answer: C Rationale: The "3 3" Phase I trial designed to determine maximum tolerated dose is an adaptive design. Adaptive design allows investigators to change trial design without compromising the integrity and validity of the trial. In a 3 3 trial, three patients start the trial at a given dose and, if no dose-limiting toxicities are observed, three more patients are added at a higher dose until the first instance of limiting toxicity is observed, then three more patients will be added at the same dose. Dose limiting toxicity in two or all three patients will identify the next lower dose as the maximum tolerated dose. Factorial design allows for multiple factors to be studied simultaneously. Parallel design randomizes participants to one of several treatment groups. Basket trials enroll patients with any cancer type sharing a specific target.

10. S.L is a 67-year-old women who was recently informed she has stage I ER/PR-positive breast cancer. The patient has a family history of breast, ovarian, and pancreatic cancer. She has an oncotype test which shows a risk score of 24. She asks her nurse what all of this means and the nurse responds with which one of the following statements? A. No risk of recurrence B. Low risk of recurrence C. Intermediate risk of recurrence D. High risk of recurrence

Answer: C Rationale: The Oncotype test is a 21-gene assay used to predict the effectiveness of chemotherapy and estimate the chance of recurrence in women with early-stage ER/PR-positive breast cancer. The recurrence score is calculated from gene expression. There is no category of no risk. Low risk is a score of 0 to 17, and the addition of chemotherapy may not be effective. A score of 18 to 31 is considered as an intermediate risk and patients need to consider other factors such as age and comorbidities when deciding whether or not to take chemotherapy. A score of higher than 31 suggests a higher risk of a recurrence, and chemotherapy is usually recommended. The Oncotype test reflects risk of recurrence based on genetic characteristics of the tumor. This female patient may have an extensive family history of cancer and possibly hereditary risk. Oncotype does not provide information about this risk.

8. Lymphoid stem cell lineage has several types of lymphocytes that play a key role in immune responses. Which one of the following cells migrate to the thymus gland for maturation and are integral to immune surveillance and response? A. NK cells B. Cytotoxic T cells C. T cells D. B cells

Answer: C Rationale: The T cells migrate to the thymus gland for maturation and are integral to immune surveillance and response. NK cells are large granular cells that release cytokines, migrate rapidly to the site of the inflammation, and directly kill tumor or viral-infected cells without previous antigen exposure. Cytotoxic T cells play a role in autoimmunity and allogenic organ rejection and destroy viral infections and cancers. B cells develop in the bone marrow and include memory B cells and plasma cells.

7. Organ and tissue components of the immune system include primary lymphoid organs and secondary lymphoid organs and tissues. Secondary lymphoid tissues are sites where antigens are captured and processed in the body. Which one of the following is an example of both primary and secondary lymphoid tissue? A. Spleen B. Lymph nodes C. Bone marrow D. Thymus

Answer: C Rationale: The bone marrow functions as both a primary and secondary lymphoid tissue. The thymus is a primary lymphoid organ and allows for the maturation of the lymphocytes. The spleen, lymph nodes, and tonsils/adenoids are examples of secondary lymphoid tissue. The spleen responds to bloodborne antigens, while the lymph nodes initiate immune responses to antigens circulating in the lymph, skin, or mucosal surfaces.

8. Which of the following is a definition of gene amplification? A. Loss of all or part of a gene found in cancer and other genetic diseases. B. Heritable change that does not alter the DNA sequence but changes gene expression. C. Increase in the number of copies of a gene that may cause cancer cell growth or resistance to anticancer drugs. D. Increase in the copies of a protein made from a gene that may play a role in cancer development.

Answer: C Rationale: The correct answer is C. Gene amplification is defined as the increase in the number of copies of a gene that may cause cancer cell growth or resistance to anticancer drugs. The loss of all or part of a gene found in cancer and other genetic diseases is defined as gene deletion (answer A). Answer B is epigenetic alteration, which is defined as a heritable change that does not alter the DNA sequence but changes gene expression. And, finally, the increase in the copies of a protein made from a gene that may play a role in cancer development is gene overexpression (answer D).

2. A nurse is assessing a patient in the clinic who has a history of non-melanoma skin cancer. Which one of the following findings would be considered a precursor for squamous cell carcinoma? A. Atypical nevi B. Multiple moles C. Actinic keratoses D. Skin viral infection

Answer: C Rationale: The correct answer is actinic keratoses (AKs). Approximately 60% to 65% of SCCs arise from prior AKs. The presence of atypical nevi and multiple moles are associated with increased risk of melanoma. Skin viral infection is associated with Merkel cell carcinoma; 80% of cases are caused by a common virus (Merkel cell polyomavirus).

8. J.C. is a 44-year-old man who presents for his annual well-visit examination and asks his nurse about prostate screening. The nurse informs him that guidelines for prostate-specific antigen (PSA) screening in men at average risk of prostate cancer recommend that screening; A. begins at age 45 years. B. is not useful for men at any age. C. should be done between ages 55 to 69 years. D. once initiated, should be repeated every year.

Answer: C Rationale: The correct answer is that UAU guidelines indicate that PSA screening between ages 55 to 69 years provides the greatest benefit. Therefore, it is not correct that results of PSA screenings are not useful for men at any age. Routine screening in men 40 to 54 years at average risk is not recommended. Men who decide to initiate PSA screening should have repeat screenings at intervals of 2 or more years.

9. The clinical trial endpoint of "time from randomization until death" is known as which one of the following terms? A. disease-free survival B. objective response rate C. overall survival D. time to progression

Answer: C Rationale: The definition of overall survival is the time from randomization until the time of death. Disease free survival is the time from randomization until recurrence of tumor or death from any cause. The objective response rate refers to the proportion of patients with a reduction of tumor size of a predetermined amount and for a minimum time period. The definition of the time to progression is the time from randomization until objective tumor progression, excluding death.

Chapter 8 Immunology 1. Recent surveillance imaging has revealed that an oncology patient, who is currently in remission, has developed new lesions. The phase of tumor suppression mechanism most likely to be implicated in this new development can be classified as which one of the following? A. elimination B. equilibrium C. escape D. progression

Answer: C Rationale: The elimination phase represents ongoing immune surveillance where the host is cancer free. In the situation above, the patient has relapsed. The equilibrium phase is a phase by which a rare tumor clone mutates to avoid elimination by the innate immune system. There is no evidence of clinically measurable disease in this phase. This does not apply to patient situation, as he/she has new lesions. The escape phase correlates with mutated tumor clones which have evaded the innate and adaptive immune systems, resulting in clinically measurable disease, as seen in this example. Progression is not a phase of the proposed tumor suppression mechanism.

5. The goal for the surgical treatment of bone/soft tissue malignancies includes which one of the following? A. amputation B. altered function C. survival D. removing the blood supply

Answer: C Rationale: The goals of surgical treatment include the following: survival, removal of the tumor, and preserving functionality. Amputation may be the chosen treatment, but it is not the goal of treatment. Removing the malignancy's blood supply is not a surgical goal of treatment.

13. Which one of the following is a definition for the hypopharynx? A. Located below the base of the tongue, and extending to but not including the true vocal cord. B. Extends from the circumvallate papillae below and hard palate above to the level of the hyoid bone. C. Extends from the hyoid bone to the lower border of the cricoid cartilage. D. Includes the nasal vestibule; paired maxillary, ethmoid, and frontal sinuses.

Answer: C Rationale: The hypopharynx extends from the hyoid bone to the lower border of the cricoid cartilage, and structures include the pyriform sinuses, the postcricoid region, and the lower posterior pharyngeal wall. The oropharynx extends from the circumvallate papillae below and hard palate above to the level of the hyoid bone; and structures include the base of the tongue (posterior one third), soft palate, and the posterior pharyngeal wall. The supraglottis is located below the base of the tongue, extending to but not including the true vocal cord, and includes the epiglottis, the aryepiglottic folds, the arytenoid cartilages, and the false vocal cords. Finally, the nasal cavity and paranasal sinuses include the nasal vestibule; paired maxillary, ethmoid, and frontal sinuses; and a single sphenoid sinus.

13. Among the following types of spinal tumors, which one, is the least common? A. Sarcomas B. Astrocytomas C. Chordomas D. Schwannomas

Answer: C Rationale: The most common type of spinal tumor of schwannomas, meningiomas, and ependymomas, comprising 79% of all spinal tumors. Chordomas are the least common of the spinal tumors. The second most common are sarcomas, followed by astrocytomas, and vascular tumors.

8. A negative genetic testing result with "known family genetic mutation" should include the following caveat: A. the technique used has limited sensitivity. B. the family may be affected by a mutation in another gene. C. family history from the other parent influences the risk of developing cancer. D. the cancer in the family may not be caused by a germline genetic mutation.

Answer: C Rationale: When an individual is tested for a known family mutation, they did not inherit the risk associated with the mutation from the side of the family with the known mutation. The history from the other side can also influence risk. A negative test result in a family with a known mutation implies at least population risk for developing malignancy and if there is risk from the other side of the family risk could be increased. A is incorrect as identification of a germline mutation in a cancer susceptibility gene also may not be possible because of the limited sensitivity of the techniques used and this can occur with both a known family mutation and when there is no known family mutation. B and D are incorrect as this can be found with a "no known family genetic mutation," and may offer a reasonable explanation as to why a mutation was not detected in a family with suspected genetic risk.

10. When caring for a patient with brain cancer, treatment with anti-epileptic medication is indicated: A. for driving B. with radiation C. peri-operatively D. at diagnosis

Answer: C Rationale: While each of these other options may seem plausible, the only correct answer is perioperatively, persons with brain cancer treatment require anti-epileptic medication in the perioperative period. Otherwise, anti-epileptic medication is not indicated unless the person has a known seizure disorder. First-line agents include lamotrigine, levetiracetam, pregabalin, or valproic acid.

11. R. J. is a 42-year-old male who is complaining of abdominal pain and has mentioned that his stools have been tarry with a foul smell. His nurse should conduct a physical examination with the suspicion that R.J. might be suffering from which one of the following? A. Chondrosarcoma B. Kaposi sarcoma C. Soft Tissue sarcoma D. Osteosarcoma

Answer: C Rationale: With complaints of worsening abdominal pain and potential blood in his stools, R. J. is presenting with possible signs of a possible soft tissue sarcoma. There may be worsening abdominal pain due to a retroperitoneal mass. When conducting her examination, the nurse may discover that the mass may or may not be visible, is firm to the touch, nontender, and possibly warm. Many soft tissue lesions can be benign. Chondrosarcoma is a cartilaginous tissue, commonly affecting the pelvis, femur, and shoulder. Kaposi sarcoma usually appears first as legions on the skin and is in the same family as Epstein-Barr virus. Osteosarcoma is commonly found in adolescents and young adults.

3. Which one of the following items is a screening technique for colorectal cancer? A. Abdominal CT B. Abdominal ultrasound C. Pelvic CT D. Immunochemical fecal occult blood test

Answer: D Rationale: A CT of the abdomen, abdominal ultrasound, and a CT of the pelvis are all staging and diagnostic procedures used in the evaluation of colon cancer, often following a positive biopsy. Screening tests for colon cancer include guaiac-based stool testing, fecal immunochemical test, immunochemical fecal occult blood test (iFOBT), barium enema, flexible sigmoidoscopy, colonoscopy, or CT colonography.

7. G.L. is a 60-year-old male patient with Stage I lung cancer. He is seen in the outpatient clinic to evaluate treatment options, including surgery. The nurse caring for him knows that the type of treatment with the least risk for morbidity includes which one of the following? A. pneumonectomy with wedge resection B. sleeve resection C. resuscitative thoracotomy D. video-assisted thoracic surgery with wedge resection

Answer: D Rationale: A VATS (video-assisted thoracic surgery) is a minimally invasive technique often done in conjunction with a wedge resection, where a wedge-shaped piece of lung tissue with a small tumor is removed, and is associated with decreased morbidity. A pneumonectomy is a surgical procedure to remove the entire lung. Overall morbidity is higher for this type of surgery. Sleeve resection is done if the tumor is in the central area of the lung and growing into the bronchus, and this is not a common surgery. A thoracotomy is a major surgical procedure done to access the chest cavity with an incision made through the chest wall. A resuscitative thoracotomy is an emergency procedure done for life-threatening emergencies such as chest hemorrhage.

3. G.R. is a 65-year-old patient who has been newly diagnosed with Philadelphia chromosome-positive acute lymphoblastic leukemia. Induction therapy has been ordered for this patient. Induction therapy would consist of which one of the following? A. allogeneic hematopoietic cell transplantation B. a pediatric chemotherapy regimen C. a monoclonal antibody and corticosteroids D. a multi-agent chemotherapy regimen in combination with a tyrosine kinase inhibitor

Answer: D Rationale: Allogeneic HCT is utilized as consolidation therapy after remission is achieved with induction therapy. Pediatric regimen is used for induction therapy in patients with Philadelphia chromosome negative disease and who are less than 65 years of age. Corticosteroids are not used as monotherapy, but in combination with TKI in patients who are less than 65 years of age. Induction therapy for individuals more than 65 years of age with a Philadelphia chromosome typically involves multi agent chemotherapy with a TKI to induce a remission and the patient who would potentially become a candidate for allogeneic HCT.

4. R.J. is a 70-year old male whose lung metastases have spread to other regions of his body. He asks the nurse attending to him how the spread of his lung metastases has occurred. The nurse explains to R.J. that the process involves feeding the tumor with oxygen and nutrients that, therefore, allows the tumor to enlarge. The process the nurse has described to her patient is called which one of the following? A. carcinogenesis B. glycolysis C. pathogenesis D. angiogenesis

Answer: D Rationale: Angiogenesis is the creation of new blood vessels from existing ones to provide nutrients and remove waste products. Carcinogenesis is the formation of a cancer where normal cells are transformed into cancer cells. Glycolysis is the breakdown of glucose by enzymes, releasing energy and pyruvic acid and is not involved in metastases. Pathogenesis of a disease is the biological mechanism that leads to the disease state, and can describe the origin and development of the disease.

5. An example of humoral immunity is: A. during antigen presentation to naïve T cells by antigen-producing cells (APCs) B. T lymphocyte activation C. the destruction of foreign particles by neutrophils D. the production of plasma cells

Answer: D Rationale: Antigen presentation refers to the process of activating T cells, which is called cell-mediated immunity. T lymphocytes activation by APCs leads to T-cell multiplication immune surveillance/ response. T lymphocytes are involved in cell-mediated immunity as part of the adaptive immune system. Neutrophils are a part of the innate immune system, not adaptive immune system. Humoral immunity involves antibodies produced by B lymphocytes. Each B cell reproduces and differentiates to become either a memory B cell or plasma cell. Plasma cells then circulate and bind to specific antigens, which starts a cascade of cytokine reactions to attract macrophages and NK cells.

5. A registered nurse at an HIV clinic educates her HIV-positive patients that they are at risk for which one of the following malignancies: A. oral and esophageal cancers B. prostate and anal cancers C. breast and ovarian cancers D. B-cell lymphoma and Burkitt lymphoma

Answer: D Rationale: Both B-cell lymphoma (NHL) and Burkitt lymphoma are AIDS-defining malignancies, as well as Kaposi sarcoma and cervical cancer. AIDS-defining malignancies are malignancies related specifically to HIV infection and the subsequently altered immune system. Non-AIDS defining malignancies include oral, esophageal, prostate, anal, breast, and ovarian cancers. 6. Answer: CRationale: HIV-infected women are at an increased risk for cervical dysplasia that rapidly progresses to cervical cancer. AIDS-defining cancers include non-Hodgkin lymphoma (NHL), Burkitt lymphoma, Kaposi sarcoma, and cervical cancer. B-cell lymphoma is the most frequently diagnosed AIDS-defining malignancy. AIDS-defining malignancies are more common shortly after initiation of active retroviral therapy, particularly among patients with low CD4 counts. Lung, acute myeloid leukemia, and kidney cancer are all non-AIDS defining cancers.

10. Chondrosarcoma is best characterized as: A. originating in the lymph nodes. B. originating in osteoid tissue. C. a pediatric disease. D. occurring in middle age (50-60 years old).

Answer: D Rationale: Chondrosarcoma originates in the cartilage and typically occurs in the pelvis, upper legs, and shoulders. Chondrosarcoma is commonly diagnosed in patients who are 50 to 60 years old, and it is not considered a pediatric disease. Lymphangiosarcoma originates from the lymph nodes. Osteosarcoma originates from osteoid tissue.

Chapter 15 Genitourinary Cancers 1. M. K. is a 59-year old male patient who has been diagnosed with clear-cell carcinoma of the kidney. The nurse caring for him is aware that which one of the following is true about this type of kidney cancer? A. The kidney cancer is an unusual type B. The kidney cancer is a type of tumor arising in the renal pelvis C. Cancer of the kidney has the worst prognosis D. Kidney cancer accounts for the majority of cases

Answer: D Rationale: Clear cell carcinoma is a common type of kidney cancer because it comprises 70% to 80% of all kidney cancer cases. Clear cell carcinoma is thought to arise in the proximal renal tubule and is not a tumor of the renal pelvis, which are considered to be very rare. Clear cell carcinoma does not have the worst prognosis among types of kidney cancers; rather collecting duct carcinomas are aggressive tumors that are associated with rapid metastasis.

4. According to the 2013 Mayo Clinic Stratification of Myeloma and Risk-Adapted Therapy (mSMART), a patient with symptomatic MM and genetic abnormalities such as of chromosome 17p, translocation of chromosomes 14 and 16, and 14 and 20 will be classified as which one of the following? A. low-risk MM B. standard-risk MM C. intermediate-risk MM D. high-risk MM

Answer: D Rationale: Deletion of chromosome 17p, translocation of chromosomes 14 and 16 and 14 and 20 are features of high-risk multiple myeloma according to Mayo Clinic mSMART Protocol. Standard risk is characterized by trisomies, t (11;14) and t (6;14) translocations, and intermediate risk is characterized by t (4;14) translocation and 1q gain by FISH. Certain characteristics may place patient at standard risk; however, there is no low-risk stratification.

2. A patient with history of exposures to an environmental carcinogen has come to a class on environmental risk and epigenetics. The audience asks "why/how" that matters. The nurse responds with the understanding that: A. epigenetics causes pieces of the DNA sequence to be "chopped out". B. only epigenetic changes associated with aging, drug use, and addiction cause cancer. C. most cancers are the result of inherited DNA and RNA mutations in single cells over the lifetime of an individual. D. changing the histone structure of DNA by allowing transcription and preventing transcription can alter the protein product outcome.

Answer: D Rationale: Epigenetics is defined as switching genes on and off with a variety of "chemical tails" attached to the DNA structure, without changing the DNA sequence. DNA transcription is controlled by opening or closing the tightly wound histone structure. This occurs by opening (allowing transcription) and closing the histone structure to alter the "DNA to RNA to protein" outcome. A is incorrect as this statement is incomplete and therefore incorrect. B is also a FALSE statement because any of the environmental effects noted can be positively (prevention) or negatively (causative) associated with development of cancer. C is a FALSE statement. Most cancers are the result of environmentally caused mutations in single cells over the lifetime of an individual.

6. Before a patient's laryngectomy, pre-operative teaching should include which one of the following? A. assessment of gait B. evaluation of endurance C. avoidance of opioid addiction D. communication strategies

Answer: D Rationale: For head and neck cancer patients, preoperative teaching covers discussion of the disease, treatment, side effects, and anticipated postoperative changes. It also includes instruction about equipment (tracheostomy tube, drains, nasogastric tube, tonsil-tip suction catheter). Before surgery, the patient should have established ways to communicate post-surgery using paper and pencil, magic slate, picture board, nonverbal cues, electronic communication board, or device. Specific for laryngectomy, the focus of preoperative teaching does not include ambulation, endurance, or opioid addiction.

11. Based on a nurse's current knowledge of survival factors in Kaposi sarcoma, the nurse understands that which of the following is true. A. there has been a dramatic decrease in survival despite the era of cART. B. the median survival is less than six months. C. prior or comorbid major opportunistic infections have no impact on survival. D. survival is shorter in patients with gastrointestinal lesions or B symptoms.

Answer: D Rationale: Gastrointestinal lesions or B symptoms (fever, night sweats, unintentional weight loss) shorten the survival in patients diagnosed with Kaposi syndrome. The era of cART has increased survival dramatically, and no decrease in survival rates has been reported. Prior or comorbid major opportunistic infections worsen survival, rather than having no impact. The median survival rate is less than one year, but not less than six months.

15. Which of the following provisions of informed consent for genetic testing is not included when consented for testing? A. Purpose of the test B. Motivation for testing C. Impact of test result on healthcare decision making D. Longevity of life after testing

Answer: D Rationale: Genetic testing cannot determine longevity of life so it is not part of the informed consent process. Answers A, B, and C are parts of the informed consent. Elements of informed consent include discussion of the purpose of the test, motivation for testing, risks and benefits of testing, potential limitations of testing, risk of misidentified paternity, inheritance pattern of the gene and likelihood of a mutation being detection, accuracy of the test, potential outcomes of testing, how confidentiality will be maintained, the possibility of discrimination, alternatives to testing, how testing will influence health care decision making, costs of testing and considerations for testing in children.

Chapter 23 Reproductive Cancers 1. Prevention of cervical cancer deaths is addressed through all of the following except: A. Papanicolaou test and human immunodeficiency virus (HIV) screening in female patients over age 21 years as per American Cancer Society (ACS), US Preventive Services Task Force (USPTF), or American College of Obstetricians and Gynecologists (ACOG) guidelines. B. vaccination against oncogenic (high-risk) hepatitis C virus subtypes. C. Attempting to conceive after the patient's hCG levels have normalized for 6-8 weeks and menses have become regular. D. addressing risk factors including encouraging regular screening exams, discussing risks of multiple partners, and discouraging tobacco use.

Answer: D Rationale: HPV vaccination, Pap testing, HPV screening, and addressing risk factors all encourage prevention, early diagnosis, and early treatment of pre-cancerous or cancerous cervical changes, which decreases the risk of death from cervical cancer. Vaccination for HPV types 16, 18, 31, 33, 45, 52, and 58 is recommended for both males and females starting at age 11 to 12. It can be given as early as age 9. Teenage boys and girls who did not get vaccinated when they were younger should be educated about the vaccine and encouraged to get it. The HPV vaccine is recommended for young women through age 26, and young men through age 21 years. Pre-invasive disease (CIN1-3) may be treated with hysterectomy if fertility sparing is not desired, but more commonly, may be treated by fertility sparing modalities such as LEEP, cone biopsy, cauterization, or cryotherapy, followed by surveillance per guidelines. There is not a vaccination for HepC. HIV screening is not routinely done in the general population.

3. A Mohs procedure is recommended to treat a patient with a non-melanoma skin cancer. In teaching the patient about what to expect, the nurse explains to the patient which one of the following? A. subzero temperature swabs will be applied to the area B. the area will be injected with a chemotherapy drug C. a curette will be used to scrape away tumor cells, then the area will be cauterized D. thin layers will be removed from the area and examined under a microscope

Answer: D Rationale: In a Mohs procedure (called Mohs micrographic surgery), the dermatologist, who has specialized training in this technique, removes tissue in successive thin layers and examines each layer under the microscope to determine the skin depth at which cancer cells are no longer present. In this way, the maximum amount of normal tissue is preserved. The other three types of therapy, cryotherapy with a probe that applies subzero temperature, local chemotherapy injection, and curettage with cautery or electrodessication, are differing techniques used for superficial low-risk skin lesions.

Chapter 11 Clinical Trials 1. A clinical trial study where participants are not assigned to a specific intervention and health care outcomes are assessed is described as which one of the following? A. experimental B. interventional C. expanded access D. observational

Answer: D Rationale: In an observational study, participants are not assigned to a specific intervention and health care outcomes are assessed. In an experimental study, participants receive specific interventions and each type is designed to answer different research questions. An interventional study is another name for experimental as described above. Expanded access occurs when a clinical research study provides a means for patients to receive an investigational drug outside of a designated clinical trial. In expanded access, the investigational agent is restricted to patients with a serious condition or disease who no longer have satisfactory medical options available and who may benefit from the investigational therapy.

4. Which one of the following statements is TRUE regarding the incidence of HIV in the United States? A. Incidence among African Americans and white gay males continues to increase. B. Diagnoses among young Hispanic/Latino gay and bisexual men has decreased. C. Heterosexual contact with HIV-infected individuals accounts for about 34% of new HIV diagnoses. D. Those older than 50 years of age are the fastest growing HIV-positive population.

Answer: D Rationale: Increases in the incidence of HIV-positive adults over 50 years of age are attributable to prolonged survival with disease, age-related physiologic changes enhancing risk of transmission, and propensity to engage in unprotected sex. Incidence among African Americans/white gay males has remained stable and not increased, while diagnoses among young Hispanic/Latino gay and bisexual men have increased, and not decreased. Hetero-sexual contact with HIV-infected individuals accounts for about 24% of new HIV diagnoses, and not 34% as is listed incorrectly in answer C.

6. Post-reconstruction management of a bone or soft tissue tumor includes a focus on which one of the following? A. thrombocytopenia B. pruritis C. cytokine response D. infection

Answer: D Rationale: Issues of reconstruction include post-surgery union of non-malignant tissue, infections, healing, and functional concerns (especially with limb salvage). Thrombocytopenia is a condition of decreased platelets (clotting blood cells). Pruritis is an allergic reaction to topical or systemic treatment. For some targeted systematic treatments, cytokine response is when cytokines and other inflammatory mediators are released.

13. As part of any patient education program, an oncology nurse must access the patient's health literacy and ability to comply with complex therapies, and multiple appointments with medical specialists. Which one of the following is an affect that health literacy has on a patient's quality of care? A. Low health literacy in patients has little impact on maintaining regular medical care. B. Low health literacy is not associated with English not being the first language spoken by a patient since interpreters are readily available at most healthcare institutions. C. Only 5% of patients who score low on a health literacy assessment have been found to maintain regular medical care. D. Studies of antiretroviral adherence reflect low rates of medication adherence among individuals with low health literacy.

Answer: D Rationale: It is correct that studies of antiretroviral adherence reflect low rates of medication adherence among individuals with low health literacy, linking a low health literacy score with adherence to medication. Low health literacy has a large - not a small - impact on maintaining regular medical care. In fact, only 17% to 40% of patients who have scored low on health literacy scores have maintained regular medical care. This statistic, though, is greater than the 5% of patients maintaining regular medical care, which is an exaggerated number, making answer C an incorrect response. Finally, low health literacy is associated with English not being the first language, mental health disorder, and lack of understanding of how to access care and support (and interpreters are not readily available in every place where healthcare is being provided).

7. Which one of the following is a potential curative therapy for hepatocellular carcinoma? A. Transarterial chemoembolization B. Nivolumab C. Sorafenib D. Liver transplant

Answer: D Rationale: Local-regional therapies include RFA, TACE, DEB-TACE, and TARE. Nivolumab and Sorafenib are palliative therapies. Liver transplant is a potentially curative option for early-stage HCC.

5. Pain in a person with MM is most commonly due to which one of the following conditions? A. anemia B. neural infiltration of plasma cells C. intestinal obstruction due to an abdominal mass D. lytic bone lesions

Answer: D Rationale: Lytic bone lesions are the most common source of pain in persons with multiple myeloma. For this reason, supportive care for persons with multiple myeloma often includes radiation therapy to the lytic lesion as well as the administration of medications such as bisphosphonates. Although there are bone marrow changes that can occur, this is not typically a source of pain. Additionally, neural infiltration of plasma cells and intestinal obstruction are also not common underlying causes of pain in multiple myeloma. Anemia is common in multiple myeloma but symptoms typically include fatigue and possibly shortness of breath, not pain.

4. S.T. is a 59-year-old female with newly diagnosed FMS-like tyrosine kinase 3-positive (FLT3 ) acute myeloid leukemia. In addition to standard-of-care induction therapy, the nurse caring for her would anticipate for the patient to be on which one of the following oral agents? A. venetoclax B. enasidenib C. ivosidenib D. midostaurin

Answer: D Rationale: Midostaurin is the only oral agent listed for FLT3 inhibition. Venetoclax is used for CLL, SLL, and newly diagnosed AML in adults 75 years or older in combination with azacitidine or decitabine or low dose cytarabine. Enasidenib is for relapsed/refractory AML with IDH2 mutations. Ivosidenib is indicated for relapsed/refractory AML with IDH1 mutations.

10. A patient presents to the clinic to discuss treatment for his new diagnosis of multiple myeloma and is ruled out as candidate for transplant. The patient asks the nurse if he has been diagnosed with a terminal disease. The nurse responds with the understanding that medication treatment in multiple myeloma: A. has a high likelihood of cure B. is curable in some trisomy translocations C. is used prior to surgery D. is aimed at controlling disease

Answer: D Rationale: No cure exists for multiple myeloma regardless of trisomy translocations and surgery is not indicated in patients with multiple myeloma for treatment of the disease. Newer therapies have extended the survival of patient with a multiple myeloma diagnosis; however, treatment in this instance is aimed at reduction and control of the disease and a palliative intent.

5. The field of pharmacogenomics has revolutionized cancer care because it: A. increased rates of non-adherence to therapy. B. lowered the cost of cancer treatment. C. increased enrollment in clinical trials. D. increased the safety and efficacy of cancer drugs.

Answer: D Rationale: Pharmacogenomics is the integration of pharmacology and genomics in developing safe and effective medications. Pharmacogenomics can determine safe doses based on genomic data. It can help reduce the use of drugs with serious or toxic side effects thereby increasing rates of adherence to therapy. It does not necessarily decrease the cost of medications or increase enrollment in clinical trials.

8. Mr. W is a 67-year-old male patient who has been newly diagnosed with chronic myelocytic leukemia. Upon review of his chart, his nurse finds that he has been diagnosed with Rai stage III, high-risk disease based on his clinical findings. His nurse anticipates that he presented with lymphocytosis and which one of the following? A. adenopathy B. thrombocytopenia <100,000 µl C. splenomegaly D. anemia hemoglobin <11 g/dl

Answer: D Rationale: Rai stage III, high-risk disease is noted to have anemia Hgb < 11 g/dL and lymphocytosis. The patient may or may not have adenopathy, hepatomegaly, or splenomegaly, and platelets counts are normal. Rai stage I, intermediate-risk disease I noted to have adenopathy and lymphocytosis (no hepatomegaly or splenomegaly, RBC and PLT counts are normal). Rai stage IV, high-risk disease is noted to have thrombocytopenia < 100,00 µL and lymphocytosis (with adenopathy, hepatomegaly and splenomegaly and RBC counts are normal or near normal). Rai stage II, intermediate-risk disease is noted to have splenomegaly and lymphocytosis (may have hepatomegaly, may or may not have adenopathy, and RBC and PLT counts are normal).

2. Cancer prediction tools include the following criteria, EXCEPT: A. demographics B. medical history C. family history D. tumor stage

Answer: D Rationale: Risk assessment tools estimate a person's risk of developing cancer over set period of years (next five years) or over a lifetime. There are tools readily available to provide estimates of the likelihood of developing cancers of the breast, colon, malignant melanoma, prostate, and lung cancers. These risk assessment models combine demographic variables such as age, gender, and ethnicity, medical history such as prior surgeries, presence of colon polyps and reproductive history, family history of malignancy, and lifestyle factors such as tobacco use, diet, and sun exposure. Tumor stage means the patient has already been diagnosed with cancer and can be a factor considered when determining prognostic information and treatment.

7. Adjuvant radiotherapy can be a component of treatment in soft tissue tumors: A. only before surgery. B. when the tumor has metastasized. C. as the primary standard of care. D. after the tumor has been debulked.

Answer: D Rationale: Soft tissue tumors can be radiosensitive and radioresponsive. So, adjuvant radiotherapy can be a component of treatment before or after surgery, when the tumor is localized or after the tumor has been surgically debulked or removed. Radiotherapy is not a treatment for distant metastatic spread of disease. For soft tissue tumors, radiotherapy is an additional modality of treatment and not the primary treatment or considered a standard of care.

6. The code of ethics and conduct that focuses primarily on beneficence, respect for persons, and justice is known as which one of the following? A. Nuremberg Code B. Declaration of Helsinki C. Common Rule D. Belmont Report

Answer: D Rationale: The Belmont Report focused primarily on beneficence, respect for persons, and justice. The Nuremberg Code focused on voluntary consent. The Declaration of Helsinki focused on informed consent, therapeutic versus non-therapeutic research, and surrogate decision making. The Common Rule, also known as the Protection of Human Research Subjects, focused on informed consent and institutional review boards.

4. An oncology nurse is caring for a 36-year-old female who is newly diagnosed patient with Hodgkin lymphoma. The staging system most commonly used for this type of lymphoma is which one of the following? A. the Tumor Nodes Metastasis staging system B. the Rai staging system of leukemia and lymphoma C. the Reed-Steenberg pathologic staging system D. the Ann Arbor Staging system

Answer: D Rationale: The Lugano Classification modification of the Ann Arbor Staging system is used to stage lymphoma. Staging is based on the extent of the disease and the presence of systemic symptoms. The Rai staging system is typically used to stage CLL. The Tumor Nodes Metastasis staging is usually used to stage solid cancers; however, the Ann Arbor Staging system is used to stage lymphomas. The Reed-Steenberg pathologic staging system is not a staging system.

11. Mr. M., a 69-year-old male, has a lymphocyte count greater than 6000 B lymphocytes/μL. His other laboratory results reveal thrombocytopenia with a platelet count of 86,000. The patient also reports he has noticed some swollen lymph nodes in the groin and the left axilla area. He also reports he has early satiety. Using the Rai staging system for CLL, the nurse determines that his extent of disease is which one of the following? A. low B. medium C. intermediate D. high

Answer: D Rationale: The Rai staging system for chronic lymphocytic leukemia defines risk or extent of disease as low, intermediate, or high. There is no medium category. Those with lymphocytosis (lymphoid cells > 30%); no lymphadenopathy, splenomegaly, or hepatomegaly are considered low. The intermediate level is defined by lymphocytosis; lymphadenopathy in any site, splenomegaly, or hepatomegaly. In both the low and intermediate levels, red blood cell and platelet counts are near normal. A high level is associated with lymphocytosis; presence of anemia (hemoglobin < 11 g/dL) or thrombocytopenia (platelet count less than 100 X 109/L) with or without lymphadenopathy, splenomegaly, or hepatomegaly. Mr. M.'s lymphocytes are greater than 6000 which indicates a more than 30% of the total white blood cell count percentage. He has thrombocytopenia, with the platelet count below 100,000. He has two sites of lymphadenopathy, the groin and axilla area, and he is having early satiety, which is likely caused by splenomegaly.

11. When administering precision medicine treatments, the healthcare team must be aware of ethical considerations of the patient. Which one of the following is an ethical concern? A. After beginning treatment of a targeted therapy, the patient develops an unexpected adverse event, leading to life-threatening complications that neither the patient nor the patient's family had expected. B. Though the patient has been educated on the topic, the side effects of a particular treatment have severely comprised the patient's quality of life. C. The cost of the treatments is such that the patient experiences financial toxicity and must stop treatment while deciding how to pay the price of drugs. D. The patient is concerned about data security and fear government intrusion that may affect health care coverage.

Answer: D Rationale: The correct answer is D. Patients provide biospecimens for biorepository and research purposes in addition to use in clinical decision making, and an ethical consideration for a patient undergoing treatment with precision medicine is whether or not their personal information is safe and secure from cyber crime as well as intrusions from the government. Adverse events and side effects are clinical concerns and not necessarily ethical considerations, and, while financial toxicity is a major concern for patients and families undergoing expensive treatments, the cost of treatment may not be an ethical concern, especially if costs were explained before treatment begins.

5. H.R. is a 67-year-old male patient. He arrives at his local infusion center to receive treatment for kidney cancer. Treatment options that have been shown to improve response rates for this type of disease include use of which one of the following? A. systemic radiation therapy B. antibody-drug conjugates C. cytotoxic chemotherapy D. immunotherapy agents

Answer: D Rationale: The correct answer is immunotherapy agents. These agents, such as interleukin-2 and interferon- alpha, have produced response rates of 10% to 15% when used as single agents for treating cancer of the kidney. Systemic radiation therapy, in which radioactive drugs are delivered either orally or intravenously, is not used to treat renal cell cancers which are not radiation sensitive. Antibody-drug conjugates, in which an antibody is linked to a cytotoxic agent, are not used to treat kidney cancer because the malignant cells do not express specific antigens that would be the target of antibodies. Cytotoxic chemotherapy has not been shown to improve survival.

8. According to the SLiM CRAB criteria myeloma-related organ dysfunction requires which one of the following diagnostic criteria for active or symptomatic multiple myeloma requiring therapy? A. Seventy percent clonal bone marrow plasma cells B. Serum-free Light chain ration Kappa: lambda < 100 C. Magnetic resonance imaging (MRI) studies with < 1 focal lesion (> 8 mm in size) D. Calcium elevation in blood, with a calcium level greater than 10.5 ng/L or the upper limit of normal

Answer: D Rationale: The diagnostic criteria for active or symptomatic multiple myeloma requiring therapy is calcium elevation in blood, with a calcium level greater than 10.5 ng/L or the upper limit of normal. Seventy percent is the incorrect percentage of clonal bone marrow plasma cells. The correct percentage is 60%. Serum-free light chain ration Kappa: lambda < 100 is incorrect. The correct answer is serum-free light chain ration Kappa: lambda > 100. Magnetic resonance imaging (MRI) studies with < 1 focal lesion (> 8 mm in size) is also incorrect. The correct answer is magnetic resonance imaging (MRI) studies with > 1 focal lesion (> 5 mm in size). Other diagnostic criteria include renal insufficiency (with a serum creatinine level greater than 2 mg/dL), anemia (hemoglobin less than 10 g/dL), bone lytic lesions (detected through a metastatic bone survey, MRI, or positron emission tomography/computed tomography (PET/CT) imaging), and bone marrow biopsy demonstrating the presence of more than 10% plasma cells.

5. C.R. is a 50-year-old male who has been a smoker all of his adult life, and now has developed lung cancer. Admitting he must make a lifestyle change, C.R. asks his oncology nurse who is caring for him about smoking cessation. The type of smoking cessation education she may provide to him includes which one of the following? A. gestalt therapy techniques B. ice chips to minimize cravings C. taking vitamin E daily D. nicotine replacement products

Answer: D Rationale: The nurse should advise C.R. on nicotine replacement products. Pharmacologic treatments include nicotine replacement therapy (NRT) such as ibuproprion and Varenicline (Champix), in addition to nicotine patches. Behavioral counseling and cognitive behavioral therapy can be used to focus on thoughts, emotions, and behaviors, and while those types of behavioral therapies are important, they are not known to be as effective as types of NRT. Gestalt therapy focuses on the here and now and isn't related to smoking cessation. Ice chips are frequently used to prevent mucositis in cancer patients, but not in smoking cessation. Vitamin E is not utilized in smoking cessation.

12. T. J. is a 41-year-old male, in good health, but whose family history of colon cancer has made him concerned about the possibility of developing colorectal cancer. Which one of the following should T.J's nurse recommend to him as a means of cancer prevention? A. Treat H. pylori, gastric ulcers B. Treat GERD C. Limit exposure to cancer-causing chemicals D. Limit alcohol intake—fewer than two drinks/day

Answer: D Rationale: The nurse should recommend to T. J. that he should limit alcohol intake to fewer than two drinks per/day as a course of action to prevent colorectal cancer. The recommendation is two drinks per/day for a male, and one drink/per day for a female. Treating H. pylori, gastric ulcers is a recommendation for the prevention of stomach cancer. Treating GERD and/or Barret's esophagitis is a prevention recommendation for esophageal cancer, while it is recommended to limit exposure to cancer-causing chemicals for prevention of hepatocellular cancer. Other recommendations for the prevention of colorectal cancer include maintaining a healthy weight, limiting red and processed meats while introducing more fruits and vegetables into a daily diet, and avoiding tobacco.

14. Which one of the following sections of the brain is responsible for a person's coordination and balance? A. temporal lobe. B. pituitary gland. C. brain stem. D. cerebellum.

Answer: D Rationale: The section of the brain responsible for coordination and balance is the cerebellum. The cerebellum is also responsible for fine muscle control. The temporal lobe accounts for language comprehension, behavior, memory, hearing, and emotions, while the parietal lobe gives us the ability to tell right from left, allows us to do mathematical calculations, allows to feel sensations, and gives us the power of reading and writing. The pituitary gland controls our hormones, growth, and fertility. The brain stem regulates and controls our breathing, blood pressure, heartbeat, and swallowing functionality.

12. Which one of the following sections of the brain would the oncology nurse most likely identify as being responsible for a person's personality? The section of the brain responsible for personality is the: A. temporal lobe B. occipital lobe C. parietal lobe D. frontal lobe

Answer: D Rationale: The section of the brain responsible for personality is the frontal lobe. The frontal lobe is responsible for not only our personality, but a person's movement, reasoning, behavior, memory, planning, decision-making, judgment, initiative, inhibition, and mood. The occipital lobe accounts for our vision. The temporal lobe accounts for language comprehension, behavior, memory, hearing, and emotions, while the parietal lobe gives us the ability to tell right from left, allows us to do mathematical calculations, allows to feel sensations, and gives us the power of reading and writing.

12. Which one of the following stages of testicular cancer has the best five-year survival rate in the United States? A. Distant B. Un-staged C. Regional D. Localized

Answer: D Rationale: The stage of testicular cancer that has the best 5-year survival rate in the United States is localized at 99.2%. Distant has a 73.2% 5-year survival rate. Unstaged has a 76.7%, while regional has a 96.1%. The overall survival rate is 95.1%.

3. When preparing to establish a treatment plan for a head and neck cancer patient, the nurse should know that the most essential part of the treatment plan will first require which one of the following? A. hereditary genetic test. B. detailed family history. C. neutrophil count. D. biopsy of the tumor.

Answer: D Rationale: To establish a treatment plan for head and neck cancer, hereditary testing is not the first step of the plan. Family history is important to assess, but it is not directly related to the treatment plan. After the patient has a treatment plan of care and it may include chemotherapy, a neutrophil count may be calculated. To establish a treatment plan for head and neck cancer, the tumor needs to be biopsied, then evaluated by a pathologist to provide information about histology, molecular, and other pathological factors.

12. E.W. is a 59-year-old man who has worked in construction doing home remodeling, renovation, and demolition for the past 25 years. He was a smoker for a brief time as a teenager but quit after only a few years and has not touched a tobacco product in the intervening years. And, yet, despite being successful in his efforts for long-term smoking cessation, he has developed lung cancer. He is overweight and has been trying unsuccessfully to control his weight for the past few years. He is confused. He only thought he could develop lung cancer from smoking. The nurse reviews his chart and decides which one of the following could have contributed to his developing of the disease? A. His gender and age. B. His weight, which is above the average for his age. C. His exposure to paint and paint thinners on the job. D. His exposure to asbestos in his career in home construction.

Answer: D Rationale: While it is true that more men (14%) will be newly diagnosed with lung cancer than woman (13%) and that 53% of all those diagnosed will be between the ages of 53 and 74, his age and gender are not factors in his diagnosis. His weight is also not a factor, though weight is a factor in many cancer cases especially colon, prostate, and breast cancers. Exposure to paint and paint thinners have been been linked with limited evidence to bladder cancer, however, environmental and occupational factors do increase the risk of developing lung cancer. His potential exposure to asbestos over his long career in home remodeling and demolition could have played a significant role in E.W.'s cancer diagnosis. Those who have been exposed to asbestos have been known to have an increased risk of developing lung cancer. Other potential factors include exposure to radon gas and air pollution.

7. Pedigree construction that identifies a family at high risk for inherited cancer should include: A. at least four generations of cancer information for both lineages. B. the use of squares to designate females and circles to designate males. C. race, ethnicity, and age of individuals, but only if there is cancer in the generation. D. history of treatments that may have reduced risk of cancer.

Answer: D. Rationale: Any individual with a diagnosis of cancer should provide information about treatments, age at onset, and other pertinent medical history that might explain the diagnosis of cancer such as risk factor exposures. A is an incorrect answer as only three generations of cancer information for both lineages is required. B is incorrect as females are designated as circles while males are designated as squares. C is incorrect as race, ethnicity, and age of individuals should be included for all of the individuals in a 3. Identification of a germline mutation in a cancer susceptibility gene may not be possible because of the limited sensitivity of the techniques used generation pedigree.

9. D.L. is a 50-year-old patient who presents to the oncology clinic with a new diagnosis of multiple myeloma. Which one of the following results is a poor prognostic indicator in this patient? A. hypocalcemia B. elevated creatinine C. normal bone scan D. plasma cells in bone marrow

Answer: is B Rationale: Patients who present with hypercalcemia, renal dysfunction, and bone fractures are associated with inferior overall survival. Hypocalcemia is not a presenting symptom for a new diagnosis of multiple myeloma and a normal bone scan would not be indicative of significant disease. Multiple myeloma is a malignancy of the plasma cells; therefore, it would be expected that plasma cells would be present in a new diagnosis.

12. A clinical trial study which explores the results of health care practices and interventions, includes patient-based outcomes, as well as the study of populations, databases, and the delivery of healthcare is described as which one of the following? A. interventional B. outcomes research C. cohort studies D. experimental

Correct Answer: B Rationale: Outcomes research explore the results of healthcare practices and interventions, and feature patient-based outcomes, as well as the study of populations and different healthcare delivery methods. The clinical trials in experimental studies are designed to answer a different research question. Cohort studies are defined as clinical trial studies where subjects who have no reported outcomes or conditions are followed and compared, based on exposure. In a cross-sectional study, described is the association between a condition and other characteristics that may exist in a specific group.

11. A clinical trial study where subjects who have no reported outcomes or conditions are followed and compared, based on exposure, is described as which one of the following? A. experimental B. outcomes research C. cohort studies D. observational

Correct Answer: C Rationale: A clinical trial study where subjects who have no reported outcomes or conditions are followed and compared based on exposure is a cohort study.In an experimental or interventional study, participants receive specific interventions. Each type of clinical trial in an experimental or interventional study is designed to answer a different research question. Studies defined as outcomes research explore the results of healthcare practices and interventions, and feature patient-based outcomes, as well as the study of populations and different healthcare delivery methods.

13. J. L. is a 49-year male with lung cancer who has recently enrolled into a clinical trial. The clinical trial explores new drug therapies to minimize toxicities related to cancer and cancer treatments. The clinical trial is an example of which one of the following? A. screening B. prevention C. quality of life D. therapeutic

Correct Answer: C Rationale: J. L. is participating in a quality of life study. This type of clinical trial explores pharmacologic or nonpharmacologic treatments to minimize toxicities related to cancer and cancer treatments. In contrast, screening trials are meant to evaluate the effectiveness of new techniques for early detection of cancer in the general populous. Diagnostic trials evaluate types of procedures or tests that may better help identify cancer in individuals who present with symptoms of the disease. Treatment or therapeutic trials evaluate the safety of new drugs, vaccines, biological agents, approaches to surgery or radiation therapy, treatment combinations, or other interventions. Even though J. L. is enrolled in a study exploring drug treatments, his trial explores treatments to minimize cancer-related toxicities, rather than exploring the safety and efficacy of new drugs or treatments.

10. Which one of the following depicts a factorial design? Randomization to treatment: A. A or B. B. A→outcome→B. C. A, B, A and B. D. A, B, A and B, placebo.

Correct answer D Rationale: The example of "A, B, A and B, placebo" represents a factorial design. Factorial design allows for multiple factors, such as multiple treatments, to be studied simultaneously. The example of "A or B" represents a parallel design. In parallel design, a participant is randomized to one of several treatment groups. The example of "A→outcome→B" represents a crossover design. A crossover design allows participants to receive more than one treatment. A, B, A and B requires placebo (neither A nor B) to be added to represent a factorial design.