Nokea
A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate?
- A. Are you getting adequate rest and sleep each day?
- B. It is normal to be fatigued even for months afterward.
- C. This is not normal and I'll let the primary health care provider know.
- D. Try adding more vitamins B and C to your diet.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client is diagnosed as having a positive reaction to the Mantoux test. Which of the following is the most appropriate nursing action?
- A. Isolate the client in a private room.
- B. Administer isoniazid (INH) as prescribed.
- C. Schedule the client for a chest x-ray.
- D. Begin a 9-month course of medication therapy.
Correct Answer: C
Rationale: The correct answer is to schedule the client for a chest x-ray. A positive Mantoux test indicates exposure to TB, but it does not confirm active disease. A chest x-ray is necessary to assess the presence of active TB disease. Isolating the client in a private room (Choice A) is not necessary based solely on a positive Mantoux test result. Administering isoniazid (INH) (Choice B) or beginning a 9-month course of medication therapy (Choice D) is premature without confirming active TB through a chest x-ray.
When educating a patient with multiple myeloma who is being discharged home, what should the nurse emphasize regarding the management of this condition?
- A. Increasing fluid intake
- B. Avoiding sunlight exposure
- C. Monitoring for signs of infection
- D. Managing pain
Correct Answer: C
Rationale: The correct answer is C: Monitoring for signs of infection. Patients with multiple myeloma have a compromised immune system, making them more susceptible to infections. Emphasizing the importance of monitoring for signs of infection helps in early detection and prompt treatment. Increasing fluid intake (choice A) is essential for many health conditions but is not the priority in managing multiple myeloma. Avoiding sunlight exposure (choice B) may be relevant for certain skin conditions or medications but is not a key aspect of multiple myeloma management. Managing pain (choice D) is important, but in the context of multiple myeloma, monitoring for signs of infection takes precedence due to the increased risk of infections in these patients.
The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?
- A. The client's pain rating
- B. Nonverbal cues from the client
- C. The nurse's impression of the client's pain
- D. Pain relief after appropriate nursing intervention
Correct Answer: A
Rationale: The correct answer is A: The client's pain rating. Pain assessment should primarily rely on the client's self-report for the most accurate determination of pain intensity. Nonverbal cues from the client (choice B) can provide additional information but should not replace the client's self-report. The nurse's impression of the client's pain (choice C) may be subjective and less reliable than the client's self-assessment. Pain relief after appropriate nursing intervention (choice D) is an important outcome but does not replace the initial assessment of the client's pain.
A patient with non-Hodgkin lymphoma (NHL) is receiving monoclonal antibody therapy. What is the priority assessment during the infusion of this medication?
- A. Vital signs
- B. Skin reactions
- C. Respiratory status
- D. Renal function
Correct Answer: A
Rationale: The correct answer is A: Vital signs. Monitoring vital signs is crucial during the infusion of monoclonal antibody therapy as there is a risk of infusion reactions such as fevers, chills, hypotension, and tachycardia. Assessing vital signs allows for early detection of any adverse reactions, enabling prompt intervention. Skin reactions (choice B), respiratory status (choice C), and renal function (choice D) are important assessments in general patient care but are not the priority during the infusion of monoclonal antibody therapy.
A nurse is caring for a patient whose diagnosis of multiple myeloma is being treated with bortezomib. The nurse should assess for what adverse effect of this treatment?
- A. Stomatitis
- B. Nephropathy
- C. Cognitive changes
- D. Peripheral neuropathy
Correct Answer: D
Rationale: The correct answer is D: Peripheral neuropathy. Bortezomib, used in the treatment of multiple myeloma, is known to cause peripheral neuropathy as a significant adverse effect. Stomatitis (Choice A), which is inflammation of the mouth and lips, is not a common adverse effect of bortezomib. Nephropathy (Choice B), referring to kidney disease, is not a typical adverse effect of bortezomib. Cognitive changes (Choice C) are not a commonly reported adverse effect of bortezomib treatment.