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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 diagnoses?
- A. Activity Intolerance
- B. Risk for Infection
- C. Acute Confusion
- D. Risk for Spiritual Distress
Correct Answer: B
Rationale: Induction therapy places the patient at risk for infection, thus this is the priority nursing diagnosis. During the time of induction therapy, the patient is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Immobility, confusion, and spiritual distress are possible, but infection is the patients most acute physiologic threat.
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A nurse is caring for a patient with Hodgkin lymphoma at the oncology clinic. The nurse should be aware of what main goal of care?
- A. Cure of the disease
- B. Enhancing quality of life
- C. Controlling symptoms
- D. Palliation
Correct Answer: A
Rationale: The goal in the treatment of Hodgkin lymphoma is cure. Palliation is thus not normally necessary. Quality of life and symptom control are vital, but the overarching goal is to cure the disease.
A patient with non-Hodgkins lymphoma is receiving information from the oncology nurse. The patient asks the nurse why she should stop drinking and smoking and stay out of the sun. What would be the nurses best response?
- A. Everyone should do these things because theyre health promotion activities that apply to everyone.
- B. You dont want to develop a second cancer, do you?
- C. You need to do this just to be on the safe side.
- D. Its important to reduce other factors that increase the risk of second cancers.
Correct Answer: D
Rationale: The nurse should encourage patients to reduce other factors that increase the risk of developing second cancers, such as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight. The other options do not answer the patients question, and also make light of the patients question.
A home health nurse is caring for a patient with multiple myeloma. Which of the following interventions should the nurse prioritize when addressing the patients severe bone pain?
- A. Implementing distraction techniques
- B. Educating the patient about the effective use of hot and cold packs
- C. Teaching the patient to use NSAIDs effectively
- D. Helping the patient manage the opioid analgesic regimen
Correct Answer: D
Rationale: For severe pain resulting from multiple myeloma, opioids are likely necessary. NSAIDs would likely be ineffective and are associated with significant adverse effects. Hot and cold packs as well as distraction would be insufficient for severe pain.
An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurses most appropriate response to the patients complaint?
- A. Call 911.
- B. Promptly refer the patient for medical assessment.
- C. Facilitate a radiograph of the patients neck and have the results forwarded to the patients primary care provider.
- D. Encourage the patient to track the size of the lymph node and seek care in 1 week.
Correct Answer: B
Rationale: Hodgkin lymphoma usually begins as an enlargement of one or more lymph nodes on one side of the neck. The individual nodes are painless and firm but not hard. Prompt medical assessment is necessary if a patient has this presentation. However, there is no acute need to call 911. Delaying care for 1 week could have serious consequences and x-rays are not among the common diagnostic tests.
A patient with a myelodysplastic syndrome is being treated on the medical unit. What assessment finding should prompt the nurse to contact the patients primary care provider?
- A. The patient is experiencing a frontal lobe headache.
- B. The patient has an episode of urinary incontinence.
- C. The patient has an oral temperature of 37.5 C (99.5 F).
- D. The patients SpO2 is 91% on room air.
Correct Answer: C
Rationale: Because the patient with MDS is at a high risk for infection, any early signs of infection must be reported promptly. The nurse should address each of the listed assessment findings, but none is as direct a threat to the patients immediate health as an infection.