Nokea
A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?
- A. Rupture of the bladder
- B. The development of a vesicovaginal fistula
- C. Extreme stress caused by the diagnosis of cancer
- D. Altered perineal sensation as a side effect of radiation therapy
Correct Answer: B
Rationale: The correct answer is B. A vesicovaginal fistula is an abnormal connection between the bladder and the vagina, leading to the passage of urine through the vagina. This condition can occur due to various reasons, including radiation therapy. Choice A, rupture of the bladder, is incorrect because a rupture would present with more severe symptoms and is not consistent with the client's description. Choice C, extreme stress, is incorrect as it does not explain the physical symptom of voiding through the vagina. Choice D, altered perineal sensation, is incorrect as it does not involve a direct connection between the bladder and the vagina.
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When working with clients experiencing alopecia, what is the best method for a nurse to help them manage the psychosocial impact of this issue?
- A. Assisting the client in pre-planning for this event.
- B. Reassuring the client that alopecia is temporary.
- C. Teaching the client ways to protect the scalp.
- D. Telling the client that there are worse side effects.
Correct Answer: A
Rationale: Assisting the client in pre-planning for alopecia is the best method to help them manage the psychosocial impact of the issue. By helping clients anticipate and prepare for the challenges associated with alopecia, they can cope better with the psychological impact. Reassuring the client that alopecia is temporary (choice B) may provide false hope as some types of alopecia are permanent. Teaching ways to protect the scalp (choice C) is important but not the most effective method for managing the psychosocial impact. Telling the client that there are worse side effects (choice D) is dismissive of the client's feelings and not helpful in addressing the psychosocial impact of alopecia.
When reviewing the safe administration of antineoplastic agents, what action should the nurse emphasize?
- A. Adjust the dose based on the patient's present symptoms.
- B. Wash hands with an alcohol-based cleanser before and after administration.
- C. Use gloves and a lab coat when preparing and administering the medication.
- D. Dispose of the antineoplastic wastes in the hazardous waste receptacle.
Correct Answer: D
Rationale: The correct answer is to dispose of the antineoplastic wastes in the hazardous waste receptacle. Antineoplastic agents are hazardous materials, and proper disposal is crucial to prevent harm to individuals and the environment. Option A is incorrect because adjusting the dose based on the patient's present symptoms may not be safe without proper authorization. Option B is incorrect as hand hygiene should be performed both before and after administering medications. Option C is incorrect as gloves and a lab coat should be worn primarily during handling and administration, not just during preparation.
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?
- A. I should avoid blowing my nose.
- B. I may need a platelet transfusion if my platelet count is too low.
- C. I should take aspirin for my headache as soon as I get home.
- D. I will count the number of pads and tampons I use when menstruating.
Correct Answer: C
Rationale: The correct answer is C. Taking aspirin is not recommended during periods of bone marrow suppression as it can increase the risk of bleeding. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can impair platelet function, further exacerbating the risk of bleeding. Choices A, B, and D are all appropriate statements for a client at risk for bleeding and undergoing chemotherapy. Blowing the nose gently, being prepared for a platelet transfusion if needed, and monitoring menstrual bleeding are all important aspects of self-care during this period.
In an adult patient, which assessment finding is considered diagnostic of Hodgkin lymphoma?
- A. Schwann cells
- B. Reed-Sternberg cells
- C. Lewy bodies
- D. Loops of Henle
Correct Answer: B
Rationale: The correct answer is B: Reed-Sternberg cells. In Hodgkin lymphoma, the presence of Reed-Sternberg cells in lymph node biopsy is diagnostic. These cells are large, atypical cells originating from B-lymphocytes. They are distinctive in appearance and are key to diagnosing Hodgkin lymphoma. Choices A, C, and D are incorrect because Schwann cells are related to nerve function, Lewy bodies are associated with Parkinson's disease, and Loops of Henle are structures in the kidney, none of which are specific to Hodgkin lymphoma.
A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnosis?
- A. Activity Intolerance
- B. Risk for Infection
- C. Acute Confusion
- D. Risk for Spiritual Distress
Correct Answer: B
Rationale: The correct answer is B: Risk for Infection. Induction therapy for acute myeloid leukemia suppresses the immune system, making the patient highly susceptible to infections due to neutropenia. Preventing infections is crucial in these patients to avoid complications. Activity Intolerance (Choice A) may be a concern, but infection prevention is of higher priority. Acute Confusion (Choice C) and Risk for Spiritual Distress (Choice D) are not the immediate priorities in this situation.