RNSG 1538 - Cellular Regulation & EOL/Grief
The nurse is collecting data from a client who is admitted to the hospital for diagnostic studies to rule out the presence of Hodgkin's disease. Which question should the nurse ask the client to elicit information specifically related to this disease?
"Have you noticed any swollen lymph nodes?
The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client needs further teaching if the client states an intention to take which action?
Apply pressure on the radiated area to prevent bleeding.
The nurse is reinforcing instructions to the client who is about to begin external radiation therapy on how to maintain optimal skin integrity during therapy. The nurse determines that there is a need for further teaching if the client states that he will do which action?
Apply tight dressings over the area to prevent bleeding.
The nurse reviews the care plan of a client with cancer and notes that the client has a problem with adequate food intake related to side effects of therapy. In order to enhance appetite and nutrition, the nurse should offer which advice to the client?
Avoid strong-smelling foods.
The nurse is assisting in the care of a client diagnosed with multiple myeloma who has been prescribed an intravenous solution. Which finding would indicate a positive response to this treatment?
Creatinine of 1 mg/dL
A client receiving chemotherapy asks the nurse, "What will I do when my hair starts to fall out?" Which action by the nurse is appropriate?
Encourage her to select a wig.
The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which finding should the nurse most likely expect to find documented in the client's record?
Enlarged lymph nodes
A client has just been told by the health care provider about her diagnosis of breast cancer. The client responds, "Oh no, does this mean I'm going to die?" The nurse interprets which response as the client's initial reaction?
Fear
A client with lung cancer receiving chemotherapy tells the nurse that the food on the meal tray tastes "funny." Which is the appropriate nursing intervention?
Provide oral hygiene care frequently.
The nurse is assisting with developing a plan of care for a client who is experiencing hematological toxicity as a result of chemotherapy. The nurse should suggest including which in the plan of care?
Restricting fresh fruits and vegetables in the diet
The nurse is preparing a client for an intravesical instillation of an alkylating chemotherapeutic agent into the bladder for the treatment of bladder cancer. The nurse provides instructions to the client regarding the procedure. Which client statement indicates an understanding of this procedure?
"After the instillation is done, I will need to change position every 15 minutes from side to side."
The nurse is collecting data from a client suspected of having ovarian cancer. Which question should the nurse ask the client to elicit information specifically related to this disorder?
"Does your abdomen feel as though it is swollen?"
The nurse has reinforced discharge instructions regarding home care to a client following a prostatectomy for cancer of the prostate. Which statement by the client indicates an understanding of the instructions?
"I should not lift anything over 20 pounds."
When reviewing the health care record of a client with ovarian cancer, the nurse recognizes which sign/symptom as being a typical manifestation of the disease?
Abdominal distention
Which of the following is correct about the rate of cell growth in relation to chemotherapy? A. Faster growing cells are less susceptible to chemotherapy B. Non dividing cells are more susceptible to chemotherapy C. Faster growing cells are more susceptible to chemotherapy D. Slower growing cells are more susceptible to chemotherapy
ANSWER C. The faster the cell grows the more susceptible it is to chemotherapy,
The nurse is taking the social history of a client diagnosed with SCLC (Single Cell Lung Cancer).Which information is significant for this disease? 1. Worked with asbestos for a short time many years ago. 2. Has no family Hx of this type of lung cancer. 3. Has numerous tattoos on upper and lower arms. 4. Has smoked 2 packs of cigarettes/day for 20 years.
Answer: 4- Has smoked 2 packs of cigarettes/day for 20 years. Rationale: Smoking is greatest risk for LC.
During the administration of a chemotherapeutic drug, the nurse observes that there is a lack of blood return from the intravenous catheter. The priority action by the nurse would be to A. stop the administration of the drug immediately B. reposition the client's arm and continue with the administration of the drug C. apply a tourniquet to the patient's affected arm and notify the doctor D. continue to administer the drug and assess for edema at the IV site
Answer A. stop the administration of the drug immediately Rationale: Chemotherapeutic agents are irritating to tissues. Lack of blood return from the IV catheter indicates that it is out of vein. Therefore, administration of the drug should be stopped immediately
A nurse is teaching a group of women about the appropriate method for performing a breast self-exam (BSE). Which of the following statements regarding breast self-exam demonstrates correct comprehension of the material? A. "Breast exams should begin around age 30." B. "Breast exams should be done one week prior to the menstrual cycle." C. "Breast exams should incorporate both feeling and looking at the breasts." D. "Breast exams should be done during the middle of the menstrual cycle."
Answer C Rationale: Breast exams should incorporate both feeling and looking at the breasts. Premenstrual swelling and tenderness of the breasts may be present one week prior. Breast self-examination should begin as early as possible, preferably when the individual is an adolescent.
A nurse is instructing a client how to decrease nausea secondary to chemotherapy and radiation. The nurse understands that the client needs more teaching if the client states, "I will try: A. eating small, frequent meals" B. Staying upright for at least on hour during meals" C. Avoiding a lot of liquids with my meals" D. Increasing the amount of unsaturated fats in my diet"
Answer D. "increasing the amount of unsaturated fats in my diet"
A charge nurse is discussing Worden's Four Tasks of Mourning with a newly licensed nurse. Which of the following statements should the charge nurse include?
Answer: "The pain of grief is experienced during the second task." Rationale: In order to complete the second task of Worden's Four Tasks of Mourning, the client must be aware of their strong emotions and allow themselves to experience the pain of grief.
client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Serum sodium levels 5. Decreased oral sodium intake 6. Medication that is antagonistic to antidiuretic hormone
Answer: 1,2,4,6 Rationale: Cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal.
A patient who smokes tells the nurse, "I want to have a yearly chest x-ray so that if I get cancer, it will be detected early." Which response by the nurse is most appropriate? 1. "Chest x-rays do not detect cancer until tumors are already at least a half-inch in size." 2. "Annual x-rays will increase your risk for cancer because of exposure to radiation." 3. "Insurance companies do not authorize yearly x-rays just to detect early lung cancer." 4. "Frequent x-rays damage the lungs and make them more susceptible to cancer."
Answer: 1-"Chest x-rays do not detect cancer until tumors are already at least a half-inch in size." Rationale: A tumor must be at least 1 cm large before it is detectable by an x-ray and may already have metastasized by that time. Radiographs have low doses of radiation, and an annual x-ray alone is not likely to increase lung cancer risk. Insurance companies do not usually authorize x-rays for this purpose, but it would not be appropriate for the nurse to give this as the reason for not doing an x-ray. A yearly x-ray is not a risk factor for lung cancer.
A nurse is teaching a client who is receiving radiation treatment for left lower lobe lung cancer. Which client statement indicates a need for further treatment? 1. "I'll use hats to protect my head from the sun when my hair falls out" 2. "If I get nauseous, I'll try to eat several small, bland meals each day" 3. "I'll allow myself plenty of time to rest between activities" 4. "Most of the adverse effects should go away shortly after my last radiation treatment"
Answer: 1-"I'll use hats to protect my head from the sun when my hair falls out" Rationale: The client requires additional teaching if he mentions that he will lose the hair on his head a result of radiation therapy. Alopecia as an acute, localized adverse effect of radiation. The treatment area for this client's cancer will be localized to the lower aspects of his lungs, not his head. Nausea and fatigue are expected generalized adverse effects of radiation therapy. Most adverse effects of radiation are temporary and will stop when treatment is complete.
The client is 4 hours post-lobectomy for lung cancer. Which assessment data warrants immediate intervention by the nurse? 1. Intake of 1500 mL IV and output of 1000 mL. 2. 450 mL of bright red drainage in the chest tube. 3. Complaining of pain at a 10 on a 1-10 scale. 4. Absent lung sound on the side of surgery.
Answer: 2- 450 mL of bright red drainage in the chest tube. Rationale: This is about a pint of blood and could indicate a hemorrhage. HINT: Blood is always a priority.
Which of the following is the primary goal for surgical resection of lung cancer? 1. To remove the tumor and all surrounding tissue 2. To remove the tumor and as little surrounding tissue as possible 3. To remove the entire tumor and any collapsed alveoli in the same region 4. To remove as much of the tumor as possible, without removing any alveoli
Answer: 2- To remove the tumor and as little surrounding tissue as possible Rationale: The goal of surgical resection is to remove the lung tissue that has a tumor in it while saving as much surrounding tissue as possible. It may be necessary to remove alveoli and bronchioles, but care is taken to make sure only what's absolutely necessary is removed.
Which clinical manifestation would the nurse expect to find in newly diagnosed intrinsic Lung Cancer? 1. Dysphagia 2. Foul smelling breath 3. Hoarseness 4. Weight loss
Answer: 3- Hoarseness Rationale: Hoarseness is an early sign.
A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis? 1. A seizure disorder 2. Chronic obstructive pulmonary disease (COPD) 3. Anemia 4. A bleeding disorder
Answer: 4- A bleeding disorder Rationale: A bleeding disorder is a contraindication for thoracentesis because a hemorrhage may occur during or after this procedure, possibly causing death. Although a history of a seizure disorder, COPD, or anemia calls for caution, it doesn't contraindicate thoracentesis.
A 69-year-old patient was diagnosed with lung cancer. He is receiving chemotherapy and the nurse caring for him reviewed the laboratory results showing a platelet count is 18,000/mm3 and a pH of 7.36. Which of the following measures would the nurse implement based on the laboratory result? 1. Contact isolation 2. Reverse isolation 3. Respiratory isolation 4. Bleeding precautions
Answer: 4- Bleeding precautions Rationale: Normal platelet count is 150,000-400,000/mm3. Bleeding precautions should be implemented with a platelet count below 50,000/mm3. Patients receiving chemotherapy are at risk for thrombocytopenia. Bleeding precautions include avoiding anticoagulant and antiplatelet medications, using an electric razor, stool softeners to prevent straining, and avoiding dental floss.
A 71-year-old patient diagnosed with lung cancer is receiving chemotherapy on an outpatient basis. The nurse must provide which of the following home care instructions to the patient? 1. During chemotherapy, use disposable plates and plastic utensils 2. All members of the family can share a bathroom 3. Do not consider urine and stool as contaminated 4. If necessary, contaminated linens should be washed separately and then washed a second time with other laundry.
Answer: 4- If necessary, contaminated linens should be washed separately and then washed a second time with other laundry. Rationale: Any contaminated linen or clothing should be washed separately and then washed a second time with other laundry to prevent exposure to chemotherapy in body fluids.
The nurse is caring for a young woman who is dying from breast cancer. The nurse determines that a defining characteristic of anticipatory grieving is present when the young woman: A. Discusses thoughts and feelings related to the loss. B. Has prolonged emotional reactions and outbursts. C. Verbalizes unrealistic goals and plans for the future. D. Ignores untreated medical conditions that require treatment.
Answer: A Rationale: The nurse can determine the client's stage of grief by observing the client's behavior. This is important because the appropriate nursing diagnoses must be developed so that the plan of care is appropriate.
For a female client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client? A. "Client verbalizes feelings of anxiety." B. "Client doesn't guess at prognosis." C. "Client uses any effective method to reduce tension." D. "Client stops seeking information."
Answer: A Rationale: Verbalizing feelings are the client's first step in coping with the situational crisis. It also helps the health care team gain insight into the client's feelings, helping guide psychosocial care. Suppressing speculation may prevent the client from coming to terms with the crisis and planning accordingly. Some methods of reducing tension, such as illicit drug or alcohol use, may prevent the client from coming to terms with the threat of death as well as cause physiologic harm. Seeking information can help a client with cancer gain a sense of control over the crisis
Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which of the following dietary modifications should the nurse recommend? A. A bland, low-fiber diet B. A high-protein, high-calorie diet C. A diet high in fresh fruits and vegetables D. A diet emphasizing whole and organic foods
Answer: A - A bland, low-fiber diet
The nurse is developing a plan of care for a client being admitted to the hospital who is immunosuppressed and will be placed on neutropenic precautions. With regard to neutropenic precautions, which intervention is incorrect? A) admitting the client to a semi-private room B) placing a precaution sign on the door to the room C) placing a mask on the client if the client leaves the room D) removing a vase with fresh flowers left by a previous client
Answer: A - admitting the client to a semiprivate room
A nurse is reviewing the medical records of a client who had surgery to stage ovarian cancer. The nurse reviews the following diagnostic notation on the pathology report: T2-N3-MX. Which of the following findings should the nurse identify as a supporting diagnosis? A. The tumor is moderate in size. B. No lymph nodes contain cancer cells. C. The tumor is receptive to current medication therapy. D. The cancer has metastasized to other areas in the body.
Answer: A The tumor is moderate in size. Rationale: A T2 designation describes the size and extent of the ovarian tumor using the tumor-node-metastasis (TNM) staging system. A T1 tumor is smaller in size, and a T4 tumor is largest.
A nurse is reviewing the health record of a client who has suspected Ovarian cancer. Which of the following findings supports this dagnosis? (Select all that apply) A. Previous treatment for endometriosis B. Family history of colon cancer C. First pregnancy at age 24 D. Report of scant menses E. Use of oral contraceptives for 10 years
Answer: A, B Rationale: Endometriosis is a risk factor for ovarian cancer. A family history of breast, ovarian, or colon cancer os a risk for ovarian cancer.
A nurse is caring for a client who has cervical cancer and is scheduled for brachytherapy. Which of the following actions should the nurse take? (Select All That Apply) A. Permit visitors to stay with the client 30 min at a time. B. Warn pregnant individuals to not visit the room.. C. Wear a dosimeter when in the client's room. D. Placed soiled dressings in a biohazard bag before discarding in the regular trash. E. Dispose of soiled linens in the hamper outside the client's room.
Answer: A, B, C Rationale: Visitors should remain for no more than 30 mins at a time and maintain a distance of at least 6 feet. Pregnant individuals should not enter the room of a client receiving brachytherapy. Healthcare personnel should wear a dosimeter when there is potential exposure to radiation, such as in the radiology department or in the room of a client receiving brachytherapy.
A nurse is caring for a client who has chronic cancer pain and has a permanent epidural catheter for administration of a fentanyl/bupivacaine solution. The nurse should monitor the client for which of the following findings? (Select all that apply) A. Respiratory depression B. Hypotension C. Sedation D. Muscle spasticity E. Sensory blockage
Answer: A, B, C, E
A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select All That Apply) A. Advise the client to keep a food diary B. Encourage the client to brush teeth before and after meals C. Assess laboratory report of ferritin D. Eat nutrient-dense foods last at meal time E. Encourage the client to limit drinking fluids during meals.
Answer: A, B, C, E Rationale: The use of a food diary assists in monitoring changes in eating habits that occur in malnutrition due to cancer. Oral hygiene before and after meals promotes increased salivation and improves taste perception. Ferritin is an indicator of the protein intake of a client who has malnutrition due to cancer. Encourage the client to limit drinking fluids with meals because fluids can cause early satiety and decrease adequate intake of food, causing malnutrition, when the client has cancer. Some fluids are needed to treat dry mouth and thickened saliva.
A nurse is caring for a client who has lung cancer and is exhibiting manifestations of Symptom of Inappropriate Antidiuretic Hormone (SIADH). Which of the following findings should the nurse report to the provider? (Select All That Apply) A. Behavioral changes B. Client report of headache C. Urine output of 40 mL/hr D. Client report of nausea E. Increased urine specific gravity
Answer: A, B, D Rationale: Behavioral changes indicate cerebral edema due to SIADH. This finding should be reported to the provider. A client report of headache indicates cerebral edema due to SIADH. This finding should be reported to the provider. A client report of nausea can indicate cerebral edema due to SIADH. This finding should be reported to the provider.
A nurse is caring for a client for who recently lost their job. Which of the following actions should the nurse take during the assessment step of the nursing process? (Select all that apply.) A. Identify whether the client is experiencing feelings of grief B. Avoid discussing the client's recent job to prevent upsetting the client C. Check the client for physical manifestations of grief D. Ask the client about their support system E. Provide education about the grief process to the client
Answer: A, C, D Rationale: The nurse should identify whether the client is experiencing feelings of grief when gathering data during the assessment step of the nursing process. The nurse should discuss the recent job loss with the client and gather data during the assessment step of the nursing process. The nurse should check the client for physical manifestations of grief they experienced during the assessment step of the nursing process. The nurse should ask the client about their support system during the assessment step of the nursing process. The nurse should provide education about the grief process to the client during the implementation phase of the nursing process.
A palliative care nurse is preparing an in-service for newly hired staff members about common grief reactions. Which of the following information should the nurse include? (Select all that apply.) A. A client who is grieving often experiences a wide range of emotions B. The anniversary date of a loss should not trigger feelings of sadness after a client has fully accepted the loss C. A client may feel a sense of relief if the death of a loved one was expected D. A client may experience difficulty concentrating and hallucinations as a psychological response to loss E. Behavioral responses to grief can include the refusal to eat or participate in social activities
Answer: A, C, D, E Rationale: A client often experiences a wide range of emotions following a loss. These feelings can include anger, numbness, sadness, anxiety, and fear. A client may experience a feeling of relief if their loved one had a serious or terminal illness and the death was expected. A client may experience difficulty concentrating and hallucinations as a psychological response to loss. A client may exhibit various behavioral responses to grief, including refusal to eat or socialize, hostile behavior, and a short temper.
The husband of a client with cervical cancer says to the nurse, "The doctor told my wife that her cancer is curable. Is he just trying to make us feel better?" Which would be the nurse's most accurate response? A. "When cervical cancer is detected early and treated aggressively, the cure rate is almost 100%" B. "The 5-year survival rate is about 75%, which makes the odds pretty good." C. "Saying a cancer is curable means that 50% of all women with the cancer survive at least 5 years." D. "Cancers of the female reproductive tract tend to be slow-growing and respond well to treatment."
Answer: A. "When cervical cancer is detected early and treated aggressively , the cure rate is almost 100%" Rationale: When cervical cancer is detected early and treated aggressively, the cure rate approaches 100%. The incidence of cervical cancer has increased among African Americans, Native Americans, and Latinas, and these women often have a poorer prognosis because the cancer is not identified early. Papanicolaou (Pap) smears and colposcopy have the potential to decrease mortality from invasive carcinoma when these screening and treatment programs are utilized by women.
A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching? A. Bottled water is an appropriate choice to increase fluid intake. B. The salad bar is a healthy choice when dining out. C. Soft-boiled eggs are an appropriate source of protein. D. Eating at a buffet is a good choice to increase caloric intake.
Answer: A. Bottled water is an appropriate choice to increase fluid intake. Rationale: Clients who have neutropenia are at risk for foodborne illness. Bottled water prevents client exposure to pathogens that may be found in other water sources.
A 40-year-old divorced mother of four school-age children is hospitalized with metastatic cancer of the ovary. The nurse finds the patient crying, and she tells the nurse that she does not know what will happen to her children when she dies. The most appropriate response by the nurse is A. "Why don't we talk about the options you have for the care of your children?" B. "Many patients with cancer live for a long time, so there is time to plan for your children." C. "For now you need to concentrate on getting well, not worry about your children." D. "Perhaps your ex-husband will take the children when you can't care for them."
Answer: A. "Why don't we talk about the options you have for the care of your children?" Rationale: This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning "Many patients with cancer live for a long time" and "For now you need to concentrate on getting well" close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's ex-husband will take the children, more assessment information is needed before making plans.
Which of the following nursing diagnoses is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? A. Acute pain B. Hypothermia C. Powerlessness D.Risk for infection
Answer: D - Risk for infection
A nurse is discussing types of grief with a group of clients who have a serious illness. Which of the following information should the nurse include? A. Anticipatory grief occurs prior to the actual loss of someone or something. B. Normal grief lasts no more than 4 months after a loss has occurred. C. Disenfranchised grief occurs when a client is unable to accept the death of a loved one. D. Prolonged grief is defined as the loss of a relationship that is considered socially unacceptable.
Answer: A. Anticipatory grief occurs prior to the actual loss of someone or something. Rationale: The nurse should include that anticipatory grief is grief that occurs prior to the loss of someone or something. Anticipatory grief is common for those who are faced with imminent death, such as a client who has been diagnosed with terminal cancer.
A nurse is caring for a client who has cancer and has a prescription for transcutaneous electrical nerve stimulation (TENS) for pain management. Which of the following actions should the nurse take? A. Apply a conductive gel before applying the electrodes from the TENS unit on the client's skin. B. Apply alcohol to the client's skin before attaching the electrodes from the TENS unit. C. Attach the electrodes from the TENS unit over painful incisions or skin damage. D. Avoid other pain medications when using the TENS unit E. Apply cold to the skin where electrodes are applied.
Answer: A. Apply a conductive gel before applying the electrodes from the TENS unit on the client's skin.
A nurse is planning care for a client who has a platelet count of 10,000/mm3. Which of the following interventions should the nurse include in the plan of care? A. Apply prolonged pressure to puncture site after blood sampling. B. Administer epoeitin alfa as prescribed. C. Place the client in a private room. D. Have the client use an oral topical anesthetic before meals.
Answer: A. Apply prolonged pressure to puncture site after blood sampling. Rationale: Implement bleeding precautions for the client who has thrombocytopenia
A nurse is caring for a client who is receiving cisplatic to treat bladder cancer, After several treatments, the client reports fatigue. Which of the following actions should the nurse take? A. Check the results of the client's most recent CBC. B. Assess the client for a hypersensitivity reaction. C. Evaluate the client for hypercalcemia. D. Examine the client for hepatomegaly.
Answer: A. Check the results of the client's most recent CBC. Rationale: The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher.
A nurse is planning care for a client who is scheduled for genetic testing for suspected cancer. Which of the following interventions should the nurse include in the plan of care? A. Determine the need for informed consent. B. Send testing results to the client's insurance agency. C. Verify the prescription of a tumor marker assay. D. Ensure the client is placed in a recovery position after testing.
Answer: A. Determine the need for informed consent. Rationale: A signed inform consent form should be obtained prior to the procedure.
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? A. Do not apply heat to the area of irradiation. B. Do not wash the area of irradiation. C. Use an antibiotic ointment to treat skin breakdown. D. Lubricate the skin lubricated with hypoallergenic lotion.
Answer: A. Do not apply heat to the area of irradiation. Rationale: This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to a potential burn injury. When outdoors in sunlight, the client should wear protective clothing over the area of irradiation.
A nurse in a clinic is talking with a client scheduled for sentinel lymph node biopsy. Which of the following information should the nurse include? A. Dye is used during the procedure B. The lymph nodes closest to the tumor are removed during the biopsy C. A small amount of chemotherapy is used to test the lymph node response D. A 2 mm plug if tissue is removed during the biopsy
Answer: A. Dye is used during the procedure Rationale: The client will receive a dye or colloid as a tracer to help identify lymph nodes during a sentinel lymph node biopsy.
A nurse is assessing a client who is experiencing disenfranchised grief. Which of the following findings should the nurse expect? A. Social Isolation B. Verbalization of acceptance of the loss C. Shares feelings of grief with others D. Hypersomnia
Answer: A. Social Isolation Rationale: Clients who are experiencing disenfranchised grief often experience social isolation, increasing their risk for depression.
A 58-year-old woman calls the health clinic when she has a moderate amount of vaginal bleeding after 6 years of menopause. The nurse will anticipate scheduling the patient for A. endometrial biopsy. B. dilation and curettage (D&C). C. laser endometrial ablation. D. uterine balloon therapy.
Answer: A. endometrial biopsy Rationale: A postmenopausal woman with vaginal bleeding should be evaluated for endometrial cancer, and endometrial biopsy is the primary test for endometrial cancer. D&C will be needed only if the biopsy does not provide sufficient information to make a diagnosis. Endometrial ablation and balloon therapy are used to treat menorrhagia, which is unlikely in this patient
After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated treatment markings. The nurse should instruct the client to take which of the following actions? A. Apply hydrating lotions. B. Apply moist heat. C. Sit in the sun for 10 min per day. D. Wash with plain soap and water.
Answer: A. Apply hydrating lotions. Rationale: The nurse should instruct the client to gently apply hydrating lotions that do not contain metal, alcohol, or perfume.
Nausea and vomiting are common adverse effects of radiation. When should a nurse administer antiemetics? A: 30 minutes before the initiation of therapy B: With the administration of therapy C: Immediately after nausea begins D: When therapy is completed
Answer: A: 30 minutes before the initiation of therapy Rationale: Antiemetics are most beneficial when given before the onset of nausea and vomiting. If the antiemetic was given with the medication or after the medication, it could lose its maximum effectiveness when needed.
The nurse is caring for a 35-year old patient receiving radiation and chemotherapy. Which statement by the patient indicates that he is using a positive coping mechanism that is useful during treatments? A: I may miss my own hair, but I have chosen a nice wig to wear B: Losing my hair won't bother me at all C: I'm never going to leave the house if I am bald D: I will not lose my hair and I'll make sure of that
Answer: A: I may miss my own hair, but I have chosen a nice wig to wear Rationale: Expressing personal feelings and positive interventions demonstrate positive coping mechanisms
After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. It will be most important for the nurse to include information about which of the following in the client's teaching plan? A: Nutritional intake B: Management of alopecia C: Exercise and activity levels D: Access to community resources
Answer: A: Nutritional intake Rationale: Clients who have had gastric surgery are prone to postoperative complications, such as dumping syndrome and postprandial hypoglycemia, which can affect nutritional intake. Vitamin absorption can also be an issue, depending on the extent of the gastric surgery. Radiation therapy to the upper gastrointestinal area also can affect nutritional intake by causing anorexia, nausea, and esophagitis. The client would not be expected to develop alopecia. Exercise and activity levels as well as access to community resources are important teaching areas, but nutritional intake is a priority need.
A client undergoing radiation therapy has a severely depressed WBC count. The nurse should include which priority nursing intervention in the plan of care? A: Place the client in a private room and maintain strict aseptic technique with all procedures B: Encourage the client to include fresh fruits and vegetables in the diet C: Educate the client to avoid shaving with a razor D: Encourage frequent visitors to reduce the client's feelings of isolation
Answer: A: Place the client in a private room and maintain strict aseptic technique with all procedures Rationale: The immunosuppressed client is at a high risk for infection. A private room, maintaining aseptic technique, and limiting visitors will reduce exposure and risk.
A nurse is teaching a client who is scheduled for nuclear imaging for suspected cancer. Which of the following statements should the nurse give? A. "The presence of a liver enzyme will be identified." B. "You will be given an injection of a radioactive substance." C. "An endoscope will be inserted through your mouth." D. "The tumor will be aspirated."
Answer: B. "You will be given an injection of a radioactive substance." Rationale: Nuclear imaging involves the administration of an oral or IV radioactive tracer to identify cancerous tissue.
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? A. Placing cool compresses on the affected arm B. Elevating the affected arm on a pillow above heart level C. Avoiding arm exercises in the immediate post-operative period. D. Maintaining an intravenous site below the antecubital area of the affected side
Answer: B Rationale: Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring
While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse what the difference is between a benign tumor and a malignant tumor. The nurse explains that a benign tumor differs from a malignant tumor in that benign tumors A. Do not cause damage to adjacent tissue. B. Do not spread to other tissues and organs. C. Are simply an overgrowth of normal cells. D. Frequently recur in the same site.
Answer: B Rationale: The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. Both types of tumors may cause damage to adjacent tissues. The cells differ from normal in both benign and malignant tumors. Benign tumors usually do not recur.
A patient has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast if which behavior is observed? A. Performs arm exercises B. Refuses to look at the dressing C. Reads the post operative care booklet D. Requests pain medication when needed
Answer: B Rationale: The patient demonstrated the most difficult adjustments to the loss if she refuses to look at the dressing. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery. Performing arm exercises is an action oriented behavior on the part of the patient and is considered a positive sign of adjustment. Reading the post operative care booklet indicates an interest in self care and is a positive action oriented option that is helpful, although there is no direct connection to adjustment to the loss of the breast.
The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient closely for which of the following abnormalities associated with this oncologic emergency? A. Hypokalemia B. Hypocalcemia C. Hypouricemia D. Hypophosphatemia
Answer: B - Hypocalcemia
A charge nurse is reviewing Kübler-Ross's five stages of grief with a newly licensed nurse. Which of the following statements should the nurse make? (Select all that apply.) A. The five stages occur in a specific order for every client B. Clients might not go through all five stages of grief C. Clients can return to a stage of grief after moving into one of the other stages D. Client who are grieving might attempt to bargain with a higher power. E. The stages of grief are only experienced by clients who have a terminal diagnosis
Answer: B, C, D Rationale: The five stages of grief model states the client may not necessarily go through all five stages of grief. The five stages of grief model states that clients may go back and forth between stages. In the five stages of grief model, the client may bargain with a higher power by making a promise to do something in exchange for a different, better outcome.
A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? Select all that apply. A. Bloating B. A non-healing sore C. Nagging cough D. Change in bowel pattern E. Change in moles
Answer: B, C, D, E
A nurse is collecting information from a client in a provider's office. Which of the following findings should the nurse identify as an indication of possible cancer? (Select All That Apply) A. Temperature 102º F (38.9º C) for more than 48hrs B. Sore that does not heal C. Difficulty swallowing D. Unusual discharge E. Weight gain 4 lb (1.8 kg) in 2 weeks
Answer: B, C, D, E Rationale: A sore that does not heal is an indicator of possible cancer. Difficulty swallowing is an indicator of possible cancer. The presence of unusual discharge is an indicator of possible cancer. Weight gain or loss is an indicator of possible cancer.
A nurse is planning care for a client who is undergoing chemotherapy and is eon neutropenic precautions. Which of the following interventions should be included in the plan of care? (Select All That Apply) A. Encourage a high fiber diet B. Eliminate standing water in the room. C. Have the client wear a mask when leaving the room. D. Have client-specific equipment remain in the room. E. Eliminate raw foods from the client's diet.
Answer: B, C, D, E Rationale: There is no benefit to a high-fiber diet for a client who has neutropenia
A nurse is caring for a client whose spouse recently died. The client is from a different culture than the nurse. Which of the following information should the nurse consider when caring for the client? (Select all that apply.) A. Rituals used to cope with loss are universal across every culture. B. Cultural-based rituals can assist clients in handling the death of a loved one C. Culture may determine how a client expresses their grief D. Cultural practices do not dictate the expected length of mourning E. Rituals regarding death direct what procedures are performed on the body after death
Answer: B, C, E Rationale: Cultural-based rituals and customs assist clients in handling the death of a loved one and proceeding through the grieving process. Cultural rituals often determine a client's expression of grief as well as specifying the amount of time grieving is allowed. Cultural rituals regarding death direct what procedures are performed on the body after death has occurred.
A 50 year old female client complains of bloating and indigestion and tells the nurse she has gained two inches in her waist recently. Which question should the nurse ask the client? A:"What do you eat before you feel bloated?" B:"Have you had your ovaries removed?" C:"Are your stools darker in color lately?" D:"Is this indigestion worse when you lie down?"
Answer: B. "Have you had your ovaries removed?" Rationale: Ovarian Cancer has vague symptoms of abdominal discomfort, but increasing abdominal girth is the most common symptom. If the client has had the ovaries removed, then the nurse could assess for another cause.
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effect? A. Anorexia and malnutrition B. Bleeding from the gums C. Diarrhea and dehydration D. Full body alopecia
Answer: B. Bleeding from the gums Rationale: Bleeding from the gums is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets.
A nurse is caring for a client 24 hr following a liver lobectomy for hepatocellular carcinoma. Which of the following laboratory reports should the nurse monitor? A. Urine specific gravity B. Blood glucose C. Serum amylase D. D-dimer
Answer: B. Blood glucose Rationale: Blood glucose should be monitored during the first 24 - 48 hours following a liver lobectomy due to decreased gluconeogenesis and stress to the liver during surgery.
A nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which of the following actions should the nurse take when the client reports bleeding gums? A. Explain to the client that this is an expected adverse effect. B. Check the value of the client's current platelet count. C. Instruct the client to use an electric toothbrush. D. Have the client make an appointment to see the dentist.
Answer: B. Check the value of the client's current platelet count. Rationale: The nurse should recognize that the bleeding is likely due to the adverse effect of the chemotherapy and needs to be evaluated further. Bleeding gums is a sign of thrombocytopenia (decreased platelet count) secondary to bone marrow suppression, which can be life-threatening in a client who is receiving chemotherapy.
A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take? A. Review laboratory test results for low hemoglobin. B. Observe for signs of infection. C. Monitor the mouth for signs of xerostomia. D. Examine the skin for generalized urticaria.
Answer: B. Observe for signs of infection. Rationale: Radiation therapy to sites containing bone marrow (such as the sternum) can lower the WBC count (leukopenia), thus increasing the client's risk for infection. Screening the client for signs of infection is essential at this time.
A charge nurse is preparing an in-service for staff members about spiritual influences on grief. Which of the following information should the nurse include? A. Many religions reject the idea of reincarnation after death. B. Religion can provide comfort during the grieving process. C. Sensitivity to religious beliefs is not a priority in the delivery of client-centered care. D. Spirituality and religious beliefs can hinder post-bereavement outcomes.
Answer: B. Religion can provide comfort during the grieving process. Rationale: Religion can provide comfort during the grieving process by providing a support system for the bereaved. Religious rituals and support can also provide comfort to those who are grieving.
A female client has a mother who died from ovarian cancer and sister diagnosed with it. Which recommendations should the nurse make regarding early detection of ovarian cancer? A:The client should consider having a prophylactic bilateral oophorectomy B:The client should have a trans-vaginal ultrasound and a CA-125 lab test every 6 months C:The client should have yearly MRI scans D:The client should have a biannual gyn exam with flexible sigmoidoscopy
Answer: B. The client should have a trans-vaginal ultrasound and a CA-125 lab test every 6 months Rationale: A trans-vaginal ultrasound is a sonogram probe is inserted into the vagina and sound waves are directed toward the ovaries. The CA-125 tumor marker is elevated in several cancers. It is nonspecific but, coupled with the sonogram, can provide info about ovarian cancer for early diagnosis.
The nurse is visiting a patient receiving radiation therapy. Which of the following statements is incorrect and requires additional teaching? A: "I may lose the ability to sweat" B: "To keep the radiation from burning my skin, I will use lotion" C: "I need to check my mouth frequently for signs of irritation" D: "During radiation therapy, I may lose some of my hair and foods may not taste right"
Answer: B: "To keep the radiation from burning my skin, I will use lotion" Rationale: Skin products must be prescribed by the physician because they can irritate the skin
When teaching safety precautions to the client with internal radiation implant, the nurse would include which statement in explanations to the client? A: No precautions are necessary for internal radiation therapy implants B: The client poses a risk of radiation exposure to others C: The client must remain in solitary isolation for the entire hospitalization D: Visitors should maintain a distance of 30 feet from the client at all times
Answer: B: The client poses a risk of radiation exposure to others Rationale: Internal radiation is emitted outward to people in close contact as long as the implant is in place. Therefore, certain precautions to protect others must be taken: The client should have a private room, and visitors should maintain a distance of 6 feet and limit visits to 10-30 minutes.
A hospitalized client with an internal radiation implant calls the nurse to the room to report the implant is dislodged and is lying in the bed. The nurse's actions would include which of the following? A: Apply gloves and place implant in a biohazard bag B: Use long-handled forceps to pick up the implant and place it into lead container C: Have client pick up the implant and place it into lead container D: Notify infection control personnel to dispose of implant
Answer: B: Use long-handled forceps to pick up the implant and place it into lead container Rationale: Direct handling of the implant causes exposure to radiation and no one should directly touch the implant. Gloves and biohazard bags do not offer protection from radiation. Long-handled forceps should be used to pick up the implant and lead containers are necessary to prevent exposure to radiation.
A 58 year old female is concerned about her risk for developing breast cancer. She began menarche at age 14, had 3 children before the age of 35, went through menopause at age 50 with an associated weight gain of 20 lbs. Which of the risk factors would contribute to this client's risk of developing breast cancer? A. menarche at age 14 B. children before the age of 35 C. postmenopausal obesity D. menopause at age 50
Answer: C Rationale: Postmenopausal obesity is a risk factor for developing breast cancer
What would be most important for the nurse to teach the patient to protect themselves from infection? A) Avoiding crowds and taking antipyretics such as Aspirin TID to avoid a fever. B) Assessing their vital signs weekly and reporting a persistent fever of 102 degrees or greater. C) Bathing daily and washing their hands frequently, especially after using restroom or handling contaminated objects. D) Interacting only with individuals who have recently been vaccinated with live or attenuated vaccines.
Answer: C - Bathing daily and washing their hands frequently, especially after using restroom or handling contaminated objects.
A nurse is caring for a client who has multiple types of skin lesions. Which of the following skin lesions are indicative of a malignant melanoma? (Select all that apply) A. Diffuse vesicles B. Uniformly colored papule C. Area with asymmetric borders D. Rough, scaly patch E. Irregular colored mole
Answer: C, E Rationale: A lesion with an asymmetric border is considered suspicious for a melanoma. A lack of uniformity of pigmentation of a mole is considered suspicious for a melanoma.
A nurse is providing teaching about colon cancer to a group of women 45 to 65 years of age. Which of the following statements should the nurse include in the teaching? A. "Colonoscopies for individuals with no family history of cancer should begin at age 40." B. "A sigmoidoscopy is recommended every 5 years -beginning at age 60." C. "Fecal occult blood tests should be done annually beginning at age 50." D. "An endoscopy provides a definitive diagnosis of colon cancer."
Answer: C. "Fecal occult blood tests should be done annually beginning at age 50." Rationale: Fecal occult blood tests should be done annually by clients starting at age 50
A nurse is teaching a client about screening prevention for cancer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to have a mammogram every 2 years beginning at age 45." B. "I should have a colonoscopy every 15 years beginning at age 60." C. "I will need to have an annual breast examination every year after 40." D. "I should have a fecal occult test done every 3 years."
Answer: C. "I will need to have an annual breast examination every year after 40." Rationale: Instruct the client that after the age of 40, they should have annual clinic breast exams
A nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching? A.. "I will take the antiemetic as soon as the chemotherapy infusion is complete." B. "I will run my toothbrush in the dishwasher every month." C. "I'll call my doctor if I notice any unusual menstrual bleeding." D. "I will avoid crowds to keep from infecting others."
Answer: C. "I'll call my doctor if I notice any unusual menstrual bleeding." Rationale: Clients should be taught bleeding precautions and to report bruising or excessive bleeding.
A nurse is planning care for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? A. "Your nausea will lessen with each course of chemotherapy." B. "Hot food is better tolerated due to the aroma." C. "Try eating several small meals throughout the day." D. "Increase your intake of red meat as tolerated."
Answer: C. "Try eating several small meals throughout the day." Rationale: Several small meals a day are usually better tolerated by the client who has nausea.
When planning care for a client being treated for cervical cancer, it would be a priority for the nurse to include which of the following in the plan of care? A. Instruction on birth control methods. B. Vigorous fluid hydration. C. Assessment of sexual function. D. Daily weights.
Answer: C. Assessment of sexual function. Rationale: Surgery and radiation therapy for cervical cancer often result in shortening of the vagina, vaginal dryness, and loss of libido due to emotional issues related to sexuality and femininity. Therefore, the client's feelings about sexuality and the partner's feelings should be assessed. If a client is not sexually active, instructions should be given in the use of a vaginal dilator and lubricant to prevent adhesion of the vaginal walls. While instruction about birth control methods may be needed for some clients, treatment for cervical cancer may include total abdominal hysterectomy, so that this would not be appropriate for all clients. Encouraging fluids and daily weights are not priorities for cervical cancer care.
In educating a client, what would the nurse NOT mention as a risk factor that increases the risk of developing endometrial cancer? A. Obesity B. Increased age C. Having had several children D. Diabetes
Answer: C. Having had several children.
A nurse is preparing for an initial visit with a client who is experiencing grief. Which of the following tasks should the nurse plan to complete first? A. Provide information to the client about the stages of grief. B. Encourage the client to share thoughts about their loss. C. Develop a relationship with the client. D. Ask the client if they are experiencing physical manifestations of grief.
Answer: C. Develop a relationship with the client. Rationale: The first task the nurse should complete during an initial visit with a client is to develop a relationship with the client. Building rapport is an important initial step of the therapeutic relationship and will assist the client to feel comfortable and share their grief with the nurse.
A nurse is caring for a client who is receiving chemotherapy and has mucositis. Which of the following actions should the nurse take? A. Use a glycerin-soaked swab to clean the client's teeth. B. Encourage increased intake of citrus fruit juices. C. Obtain a culture of the lesions. D. Provide an alcohol-based mouthwash for oral hygiene.
Answer: C. Obtain a culture of the lesions. Rationale: Obtain a culture of the lesions to identify pathogens and determine appropriate treatment.
The nurse is making a home visit to a client receiving external radiation therapy on an outpatient basis. Further teaching is necessary when the nurse observes the client doing which of the following? A: Washing radiation site with plain water and patting skin dry B: Protecting skin with soft, loose clothing C: Applying lotion to irritated skin D: Inspecting skin for damage
Answer: C: Applying lotion to irritated skin Rationale: Lotion, deodorant, and powders should not be applied to the radiation site during the treatment period to avoid further irritation to the skin.
The nurse is caring for a client admitted to the surgical unit following a right modified radical mastectomy. The nurse includes which of the following in the nursing plan of care? A. Take blood pressure in the right arm only. B. Draw serum laboratory samples from the right arm only. C. Position the client supine with the right arm elevated on a pillow. D. Check the right posterior axilla area when assessing the surgical dressing.
Answer: D Rationale: If there is drainage or bleeding from the surgical site after a mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the drainage first. The nurse checks this area to detect early bleeding. The patient should be positioned with the head of the bed in semi-Fowler's position and the arm elevated on pillows to decrease edema. Edema is likely to occur because lymph drainage channels have been resected during the surgical procedure. Blood pressure management, venipuncture, and intra-venous sites should not involve use of the operative arm.
The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which of the following strategies would be most appropriate for the nurse to use to increase the patient's nutritional intake? A) Increase intake of liquids at mealtime to stimulate appetite. B) Serve three large meals per day plus snacks between each meal C) Avoid the use of liquid protein supplements to encourage eating at mealtime D) Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods
Answer: D - Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.
A nurse is caring for a client who was admitted to receive chemotherapy for treatment of ovarian cancer. The client vomited after each previous dose of chemotherapy. Which of the following actions should the nurse take to prevent vomiting? A. Speak to the provider about decreasing the chemotherapy dose B. Withhold food and fluids prior to and during treatment C. Provide the client with an emesis basin during treatment D. Administer and antiemetic prior to chemotherapy
Answer: D - Administer an antiemetic prior to chemotherapy
A nurse is teaching a client who is scheduled for a shave biopsy for suspected cancer. Which of the following client statements indicates understanding of the procedure? A. "A test of my bone marrow will be performed." B. " A lymph node will be removed." C. "A needle will be inserted into the mass." D. "A small skin sample will be obtained."
Answer: D. "A small skin sample will be obtained." Rationale: A shave biopsy is a sampling of the outer skin layer using a scalpel or razor blade
A nurse is using the NURSE mnemonic while speaking with a client who is experiencing grief. Which of the following responses by the nurse demonstrates the concept represented by the "U" in the NURSE mnemonic? A. "What is the most challenging aspect for you at this time?" B. "I am going to be here for you all night." C. "It sounds like you may be feeling overwhelmed." D. "There is a lot going on right now, how can I be of help to you?"
Answer: D. "There is a lot going on right now, how can I be of help to you?" Rationale: This statement demonstrates the concept of Understanding in the NURSE mnemonic. The nurse recognizes what the client is feeling and has an opportunity to provide support to the client.
A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take? A. Tell the client to expect dark stools following chemotherapy. B.Have the client floss 4 times daily. C. Have the client swish with commercial mouthwash before therapy. D. Administer an antiemetic prior to the procedure.
Answer: D. Administer an antiemetic prior to the procedure. Rationale: The nurse can help prevent nausea and vomiting by administering an antiemetic prior to chemotherapy, and to tell the client to continue taking medication until nausea and vomiting resolve.
A nurse is caring for a client who was recently diagnosed with chronic kidney disease. The client asks the nurse, "Why me? This is not fair." The nurse should identify the client's statement as an expression of which of the following stages of grief? A. Denial B. Depression C. Bargaining D. Anger
Answer: D. Anger Rationale: Anger is one of the five stages of grief where the client wonders, "Why me?" and feels, "It is not fair." The client is trying to adjust to the loss and is experiencing emotional distress.
Mina, who is suspected of an ovarian tumor, is scheduled for a pelvic ultrasound. The nurse provides which pre-procedure instruction to the client? A. Eat a light breakfast only B. Maintain an NPO status before the procedure C. Wear comfortable clothing and shoes for the procedure D. Drink six to eight glasses of water without voiding before the test
Answer: D. Drink six to eight glasses of water without voiding before the test Rationale: A pelvic ultrasound requires the ingestion of large volumes of water just before the procedure. A full bladder is necessary so that it will be visualized as such and not mistaken for a possible pelvic growth. An abdominal ultrasound may require that the client abstain from food or fluid for several hours before the procedure. Option C is unrelated to this specific procedure.
A woman tells the nurse that "there's been a lot of cancer in my family." The nurse should instruct the client to report which possible sign of cervical cancer? A. Pain B. Leg edema C. Urinary and rectal symptoms D. Light bleeding or watery vaginal discharge
Answer: D. Light bleeding or watery vaginal discharge. Rationale: In its early stages, cancer of the cervix is usually asymptomatic, which underscores the importance of regular Pap smears. A light bleeding or serosanguineous discharge may be apparent as the first noticeable symptom. Pain, leg edema, urinary and rectal symptoms, and weight loss are late signs of cervical cancer.
A nurse is assessing a client who is getting divorced and reports feelings of loss associated with no longer being in the role of a spouse. The nurse should identify that the loss of a previously held role is which of the following types of losses? A. Loss of autonomy B. Loss of dreams and expectations C. Loss of safety D. Loss of identity
Answer: D. Loss of identity Rationale: Clients who experience the loss of identity have lost either a role or a relationship, such as after a divorce when a client is no longer in the role of a "spouse."
A nurse is caring for a client who has leukemia and has developed thrombocytopenia. Which of the following actions should the nurse take first? A. Plan for the client to take rest periods throughout the day. B. Encourage the client to cough, turn, and deep breath every 2 hr. C. Assess temperature every 4 hr D. Monitor platelet counts.
Answer: D. Monitor platelet counts. Rationale: The greatest risk to the client who has thrombocytopenia is injury due to bleeding. The priority action for the nurse to take is to monitor the client's platelet level to ensure it does not reach critical levels.
A nurse is assessing a 16-year-old client whose parent recently died. Which of the following findings should the nurse expect? A. The client is still developing an understanding of death. B. The client feels that "everyone understands me." C. The client can easily express their emotions. D. The client displays high-risk behaviors.
Answer: D. The client displays high-risk behaviors. Rationale: The nurse should identify that a 16-year old client whose parent has recently died might display high-risk behaviors because they have difficulty expressing their feelings.
A 22 year old client asks about the purpose of the HPV vaccine (Gardasil). What is an appropriate nursing explanation? A. It is to lower the risk of contracting melanoma. B. It is a vaccine that prevents infection by all strains of HPV. C. The vaccine treats infections of HPV. D. The vaccine can lower the risk of cervical cancer.
Answer: D. The vaccine can lower the risk of cervical cancer. Rationale: The HPV vaccine can prevent infection by certain strains of HPV, not all strains. It is useful in that it can lower the risk of developing cervical cancer. It does not treat preexisting infection, but can prevent infection by other types.
At a senior citizen program, the nurse who was invited to speak to the group is teaching them about detecting the early signs of cancer. Which of the following should the nurse include? A: Do not overexpose yourself to the sun B: Exercise for no more than 7 minutes a day C: Lower the amount of fats in your diet D: Do a monthly breast self-exam
Answer: D: Do a monthly breast self-exam Rationale: Monthly breast exams aid in early detection of cancer. Changing the patients diet and limiting exposure to the sun may help with prevention but not detection.
A nurse is caring for an adult client who is mourning the death of a sibling. Which of the following information should the nurse consider when caring for the client?
Answer: Grief differs for adults due to their full understanding of death and memories of the deceased. Rationale: Grief is different in adulthood as compared to other stages of growth and development as adults have full comprehension of death and have memories of the deceased.
A charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching? A. Keep artificial nails trimmed. B. Use alcohol-based hand rubs before administering eye drops for a client. C. Wash hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile. D. Use chlorhexidine to wash hands if the client is immunosuppressed.
Answer: d. Use chlorhexidine to wash hands if the client is immunosuppressed. Rationale: The CDC recommends health care workers use chlorhexidine for hand washing when providing care to a client who is immunosuppressed.
A nurse is counseling the family of patient who has terminal breast cancer about palliative care. The nurse explains that which of the following are goals of palliative care? Select all that apply. A. Delays death B. Offers a support system C. Provides relief from pain D. Enhances the quality of life E. Focuses only on the patient not the family F. Manages symptoms of disease and therapies
Answers: B, C, D, F Rationale: Palliative care is a philosophy of total care. Palliative care goals include the following: providing relief from pain and other distressing symptoms, affirming life and regarding dying as a normal process, neither hastening nor postponing death, integrating psychological and spiritual aspects of client care, offering a support system to help the client live as actively as possible until death, offering a support system to help families cope during the client's illness and their own bereavement, and enhancing the quality of life.
The nurse is caring for a client after a mastectomy. Which finding would indicate that the client is experiencing a complication related to the surgery?
Arm edema on the operative side
The nurse working in an obstetrical-gynecological health care provider's office is instructing a small group of female clients about breast self-examination (BSE). Which instructions should the nurse reinforce?
BSE should be performed 1 week after menstruation begins.
The nurse is caring for a client dying of ovarian cancer. During care, the client states, "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing?
Bargaining
A cervical radiation implant is placed in the client for treatment of cervical cancer. Which activity would the nurse most likely expect to note in the health care provider's prescriptions?
Bed rest
A client who has just been told by the health care provider that she has breast cancer responds by stating, "Oh, no, this has to be a big mistake." The nurse interprets the client's initial response as which type of reaction?
Denial
The nurse is assisting in caring for a client with an inoperable lung tumor and helps develop a plan of care by addressing complications related to the disorder. The nurse includes monitoring for the early signs of vena cava syndrome in the plan. Which early sign of this oncological emergency should the nurse include monitoring for in the plan of care?
Edema of the face and eyes
The nurse is developing a plan of care for a client following a radical mastectomy and includes measures that will assist in preventing lymphedema of the affected arm. The nurse should include which action to prevent this complication?
Elevate the affected arm on a pillow.
The nurse is caring for a client after a mastectomy. Which nursing intervention should assist with preventing lymphedema of the affected arm?
Elevating the affected arm on a pillow above heart level
A client with ovarian cancer is scheduled to receive chemotherapy with cisplatin. The nurse assisting in caring for the client reviews the plan of care, expecting to note which intervention?
Encourage fluids
A client with endometrial cancer is receiving doxorubicin (Adriamycin), an antineoplastic agent. The nurse should specifically collect data about which criterion?
Hematological laboratory values
The nurse is reviewing the record of a client with a diagnosis of cervical cancer. Which should the nurse expect to note in the client's record related to a risk factor associated with this type of cancer?
History of human papillomavirus
The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding would provide information about the massive cell destruction that occurs with the chemotherapy?
Increased uric acid level
The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 cells/mm3. On the basis of this laboratory value, the nurse should collect which data as a priority?
Level of consciousness
The nurse is assisting with conducting a health-promotion program at a local school. The nurse determines that there is a need for further teaching if a student identifies which as a risk factor associated with cancer?
Low-fat and high-fiber diets
A client with cancer is receiving chemotherapy and develops thrombocytopenia. Which intervention is a priority in the nursing plan of care?
Monitor the client for bleeding.
The nurse is assisting in planning care for a client with Hodgkin's disease who is neutropenic as a result of radiation and chemotherapy. Which actions would be included in the client's plan of care? Select all that apply.
Monitor white blood cell counts daily. Ensure meticulous hand washing before caring for the client. Ask visitors with respiratory infection symptoms to not visit the client.
A client is receiving radiation therapy to the brain because of a diagnosis of a brain tumor. Which side/adverse effect does the nurse expect the client is likely to experience?
Nausea & Vomiting
A nursing instructor asks a nursing student about the characteristics of Hodgkin's disease. The instructor determines that the student needs to read about the characteristics of this disease if the student states that which is an associated characteristic?
Occurs most often in older adults
The nurse is reinforcing instructions to a group of female clients about breast self-examination (BSE). When should the nurse instruct the client to perform this examination?
One week after menstruation begins
The nurse is reinforcing instructions to a client scheduled for conization in 1 week for the treatment of microinvasive cervical cancer. The procedure has been explained by the health care provider, and the nurse is reviewing the complications associated with the procedure. The nurse determines that the client needs further teaching if the client states that which is a complication of this procedure?
Ovarian perforation
A client is tentatively diagnosed with ovarian cancer. The nurse gathers data about which late symptom of this disease?
Pelvic pain, anemia, and ascites
A client with cancer is at risk for experiencing vena cava syndrome. The nurse should monitor this client for which early sign of this oncological emergency?
Periorbital edema
The nurse is assisting in developing a postoperative plan of care for a client following a mastectomy. Which interventions will be included in the plan of care? Select all that apply.
Place the affected arm on a pillow. Check the incision for signs of infection. Monitor and measure drainage in the collection device.
The nurse is orienting a new nurse to the care of a client who has an internal radiation implant. The nurse includes which instructions in discussions with the new nurse?
Pregnant women are not allowed in the client's room.
The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which may be prescribed to treat this complication? Select all that apply.
Radiation Chemotherapy Serum sodium blood levels Medication that is antagonistic to antidiuretic hormone (ADH)
The nurse reviews the care plan of a client with cancer undergoing chemotherapy. The nurse notes that the client has a concern about her appearance as a result of alopecia. The nurse plans to tell the client which information about hair loss and regrowth to assist the client in coping with this possible change?
Regrown hair may have a different color and texture.
The nurse is reviewing the medical history of a client admitted to the hospital with a diagnosis of colorectal cancer. The nurse understands that which information documented in the medical history is an unassociated risk factor of this type of cancer?
Regular consumption of a high-fiber diet
The nurse is assisting in caring for a client receiving chemotherapy. On review of the morning laboratory results, the nurse notes that the white blood cell count is extremely low, and the client is immediately placed on neutropenic precautions. The client's breakfast tray arrives, and the nurse inspects the meal and prepares to bring the tray into the client's room. Which action should the nurse take before bringing the meal to the client?
Remove the fresh orange from the breakfast tray.
The nurse is caring for a client in the oncology unit who has developed stomatitis during chemotherapy. The nurse should plan which measure to treat this complication?
Rinse the mouth with dilute baking soda or saline solution.
The nurse is caring for a client with metastatic lung cancer. The client was medicated 2 hours ago and now reports a new and sudden sharp pain in the back. The nurse appropriately interprets this finding as possibly indicating which complication?
Spinal cord compression
The nurse's teaching plan for a client with a family history of breast cancer should include which important item?
Teaching the breast self-exam technique to be done every month
The nurse is preparing a client with a bowel tumor for surgery. The health care provider has informed the client that the surgery is palliative in the treatment of the tumor. Which rationale is the reason to perform this type of surgery?
To reduce pain
The nurse reinforces instructions to the client about breast self-examination (BSE). The nurse instructs the client to lie down and examine the left breast. Which is the correct area for placing a pillow when examining the left breast?
Under the left shoulder
The nurse answers the call bell of a client who had insertion of an internal cervical radiation implant. The client states that the implant fell out, and the nurse sees it lying in the bed after moving back the sheet. Which action should the nurse take?
Use long-handled forceps to place the implant in a lead container.
