Nokea
After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. 35-year-old who has wet desquamation associated with abdominal radiation
- B. 42-year-old who is sobbing after receiving a new diagnosis of ovarian cancer
- C. 24-year-old who is receiving neck radiation and has blood oozing from the neck
- D. 36-year-old who has a new pericardial friction rub after receiving chest radiation
Correct Answer: C
Rationale: Since neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening.
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When caring for a patient with a temporary radioactive cervical implant, which action by the student nurse indicates that the unit nurse should intervene?
- A. The student flushes the toilet once after emptying the patient's bedpan.
- B. The student stands by the patient's bed for 30 minutes talking with the patient.
- C. The student places the patient's bedding in the laundry container in the hallway.
- D. The student gives the patient an alcohol-containing mouthwash to use for oral care.
Correct Answer: B
Rationale: Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine or feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.
The nurse is caring for a patient with cancer who has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which of the following nursing actions is most appropriate?
- A. Add strained baby meats to foods such as casseroles.
- B. Teach the patient about foods that are high in nutrition.
- C. Avoid giving the patient foods that are strongly disliked.
- D. Put extra spice in the foods that are served to the patient.
Correct Answer: C
Rationale: The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition.
The nurse is caring for a patient undergoing external radiation and has developed a dry desquamation of the skin in the treatment area. Which of the following patient statements indicates that the nurse's teaching about management of the skin reaction has been effective?
- A. I can buy some aloe gel to use on the area.
- B. I will expose the treatment area to a sun lamp daily.
- C. I can use ice packs to relieve itching in the treatment area.
- D. I will scrub the area with warm water to remove the scales.
Correct Answer: A
Rationale: Aloe gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.
The nurse is teaching a patient who is postmenopausal and has stage III breast cancer about the expected outcomes of her cancer treatment. Which patient statement indicates that the teaching has been effective?
- A. After cancer has not recurred for 5 years, it is considered cured.
- B. The cancer will be cured if the entire tumour is surgically removed.
- C. Cancer is never considered cured, but the tumour can be controlled with surgery, chemotherapy, and radiation.
- D. I will need to have follow-up examinations for many years after I have treatment before I can be considered cured.
Correct Answer: D
Rationale: The risk of recurrence varies by the type of cancer. For breast cancer in postmenopausal women the patient needs at least 20 disease-free years to be considered cured. Some cancers are considered cured after a shorter time span, or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.
The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which of the following snack choices by the patient indicates that the teaching has been effective?
- A. Orange sherbet
- B. Fresh fruit salad
- C. Strawberry yogurt
- D. Cream cheese bagel
Correct Answer: C
Rationale: Yogurt has high biological value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Orange sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein.