test 4
A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis?
"I am fat and ugly."
A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond?
"Let's talk to the ostomy nurse to help you and your husband work through this."
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?
"The biopsy will help decide the treatment for my enlarged prostate."
A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best?
"The donor's cells are actually attacking the client's cells."
A nurse cared for a client who has a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond?
"The stool will always be liquid with this type of colostomy."
A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the client's white blood cell count (WBC) is high. What response by the registered nurse is best?
"Those WBCs are abnormal and don't provide protection."
A nurse has taught the parents about home care of their child who has leukemia. What statement made by the parents indicates an understanding of this teaching?
"We will take our child's temperature frequently."
A patient who was referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patient's oral intake, the nurse should ask:
"What do you eat in a typical day?"
A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (SELECT ALL THAT APPLY)
"chemo" gloves facemask isolation gown
A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer?
A 72-year-old who eats fast food frequently
A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach his client?
Add vegetables such as broccoli and cauliflower to your new diet.
A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate?
Administer prescribed antiemetics 1 hour before the treatments.
A nurse has taught parents about diagnostic testing for their child who is suspected of having leukemia. What test described by the parents shows good understanding of this information?
Bone marrow biopsy
The nurse understands that the types of precautions needed for children receiving chemotherapy are based on which actions of chemotherapeutic agents?
Bone marrow suppression
A student studying leukemias learns the risk factor for developing this disorder. Which risk factors does this include? (SELECT ALL THAT APPLY)
Chemical exposure ionizing radiation exposure viral infections
A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first?
Client who has two bloody diarrhea stools this morning.
The nurse assessed a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?
Crackles heard at the lung bases.
The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met?
Doing activities of daily living (ADLs) using rest periods.
What is a priority nursing diagnosis for the 4-year-old child newly diagnosed with leukemia?
Risk for infection related to immunosuppressed state.
A child with a history of fever of unknown origin, excessive bruising, lymphadenopathy, anemia, and fatigue is exhibiting symptoms most suggestive of which of the following?
Leukemia
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely?
Anorexia nervosa
A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis?
Imbalanced nutrition; less than body requirements, related to self-starvation
A client is starting hormonal therapy with tamoxifen (Nolvadex) to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug?
It selectively blocks estrogen in the breast.
A patient has been assigned the nursing diagnosis of imbalanced nutrition; less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?
Apply the ordered anesthetic gel to oral lesions before meals.
A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is the priority?
Assess blood pressure and pulse.
A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important?
Assist the client in getting out of bed.
While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention?
Prioritization and administration of nursing care throughout the day
A women diagnosed with breast cancer had these laboratory tests performed at an office visit: Alkaline phosphatase 125 U/L, Total calcium 12 mg/dL, Hematocrit 39%, Hemoglobin 14 g/dL. What test results indicate to the nurse that some further diagnostics are needed?
Elevated alkaline phosphatase and calcium suggests bone involvement.
A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which actions should the nurse take?
Encourage the client to verbalize feelings about the diagnosis.
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem?
Encourage the patient to purchase a wig or hat and wear it once hair loss begins.
A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer?
Epoetin alfa (Epogen)
What is the priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia?
Fatigue related to decreased cellular oxygenation
With a history of breast cancer in the family, a 48-year-old female client is interested in learning about the modifiable risk factors for breast cancer. After the nurse explains this information, which statement made by the client indicates that more teaching is needed?
I am glad that we can still have wine with every evening meal.
As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented?
Lanugo
During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?
Obtain more information about the family history
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?
Patient has crackles up to the midline posterior chest.
A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain?
Patient involved in decision making increases a sense of control and promotes compliance with the treatment.
After change-of-shift report on the oncology unit, which patient should the nurse assess first?
Patient who is neutropenic and has a temperature of 100.5F
The nurse notes that a child's gums bleed easily and that the child has bruising and petechiae on his extremities. What laboratory values are consistent with these symptoms?
Platelet count of 19,000/mm^3
What fluid is the best choice when a child with mucositis asks for something to drink?
Popsicle
A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended?
Prostate-specific antigen
During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looking away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?
Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis.
The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?
Shortness of breath
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?
Stop the infusion if swelling is observed at the site.
A client has just returned from a right radical mastectomy. Which action but the unlicensed assistive personnel (UAP) would the nurse consider unsafe?
Taking the blood pressure on the right arm.
What behavior by a nurse caring for a patient diagnosed with an eating disorder indicates the nurse needs supervision?
The nurse uses an authoritarian manner when interacting with the patient.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would include a need for further teaching?
The patient's visitors bring in fresh peaches.
The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer?
Using skin protection during sun exposure while at the beach
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?
White blood cells (WBC) 2700/µL
A child with acute myeloblastic leukemia is scheduled to have a bone marrow transplant (BMT). The donor is the child's own umbilical cord blood that had been previously harvested and banked. This type of BMT is termed
autologous
A nursing diagnosis for a patient diagnosed with bulimia nervosa is ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is, "Within 2 weeks the patient will:
identify two alternative methods of coping with loneliness."
A client has a platelet count of 9800/mm^3. What action by the nurse is most appropriate?
instruct the client to call for help to get out of bed
A nurse is conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of:
processing the heightened anxiety associated with eating.
Physical assessment of a patient diagnosed with bulimia nervosa often reveals:
prominent parotid glands
Parents of a child with acute lymphoblastic leukemia (ALL) ask about their child's prognosis. The nurse should base the response on the knowledge that
the majority of children go into remission and remain symptom free when treatment is completed.
