Nokea
The signs and symptoms of heart failure do not include:
- A. Dyspnoea
- B. Orthopnoea
- C. Urinary frequency
- D. Fatigue
Correct Answer: C
Rationale: Heart failure floods breathless, flat-lie gasps, swelling, wiped out. Peeing often? Kidneys, not heart others scream pump fail. Nurses clock these, a chronic wet mess minus bladder.
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A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?
- A. Blood pressure
- B. Lung assessment
- C. Oral mucous membranes
- D. Skin integrity
Correct Answer: A
Rationale: Interleukins, a type of biologic response modifier used with chemotherapy, can cause capillary leak syndrome, where fluid shifts from blood vessels into tissues, leading to hypotension and edema. This makes blood pressure the priority assessment, as a drop could indicate intravascular depletion, risking shock or organ failure if undetected. Lung assessment is relevant for potential pulmonary edema, but hypotension precedes respiratory distress in this context. Oral mucous membranes and skin integrity matter for chemotherapy's broader effects (e.g., mucositis, rashes), but these are less urgent than hemodynamic stability. Monitoring blood pressure first ensures early detection of a life-threatening complication, aligning with nursing's focus on airway, breathing, and circulation principles, critical in managing interleukin therapy's systemic impact.
Which of the following factors has a major impact on the development of chronic illness?
- A. Poverty
- B. Social stability
- C. Urban dwelling
- D. High school diploma
Correct Answer: A
Rationale: Poverty slams chronic illness cash shortages spike stress, skimp care, and fuel risks like poor diet, a root driver nurses see in diabetes or heart woes. Stability's a buffer, urban life's neutral, education helps but lacks poverty's punch. Socioeconomic holes breed disease, a chronic trap clinicians fight.
A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia?
- A. Interrupted sleep pattern
- B. Hot flashes
- C. Epistaxis (nose bleed)
- D. Increased weight
Correct Answer: C
Rationale: Carmustine, a nitrosourea, slams bone marrow, dropping platelets and causing thrombocytopenia low counts mean bleeding risks soar. Epistaxis (nosebleeds) is a classic sign, as mucosal vessels lack clotting support, especially with counts below 50,000/µL. Sleep issues might tie to discomfort but aren't direct. Hot flashes link to hormonal therapies, not this. Weight gain's unrelated cancer often causes loss. Nurses zero in on bleeding like epistaxis, bruising, or petechiae checking daily for these red flags, vital in oncology to catch and manage this life-threatening chemo fallout early.
The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?
- A. Nausea
- B. Alopecia
- C. Hematuria
- D. Xerostomia
Correct Answer: C
Rationale: Intravesical chemo (e.g., BCG for bladder cancer) targets the bladder lining directly hematuria (blood in urine) is the biggie to watch, signaling irritation or tumor breakdown. It's local, not systemic, so nausea and alopecia whole-body effects from IV chemo don't fit. Xerostomia (dry mouth) might tag along with systemic agents hitting salivary glands, not this route. Nurses track hematuria here because it's the bladder's cry for help, a common, expected reaction to drugs bathing the mucosa. In oncology, knowing delivery matters intravesical skips the bloodstream, keeping side effects bladder-focused, critical for patient comfort and spotting complications early.
A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem?
- A. The patient requests that her family bring her makeup and wig
- B. The patient begins to discuss the future with her family
- C. The patient reports less disruption from pain and discomfort
- D. The patient cries openly when discussing her disease
Correct Answer: A
Rationale: Alopecia guts self-image, especially at 16 requesting makeup and a wig shows she's fighting back, reclaiming her look and confidence. It's active, not passive, unlike future talks (hopeful but vague), less pain (physical, not emotional), or crying (raw but not progress). Nurses in oncology cheer this, knowing it signals resilience against chemo's brutal psychosocial hit, a win for body image goals.