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During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?
- A. Risk for ineffective adherence to treatment related to denial of need for chemotherapy
- B. Acute confusion related to infiltration of leukemia cells into the central nervous system
- C. Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment
- D. Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis
Correct Answer: D
Rationale: New leukemia diagnosis plus restlessness and repeat requests scream anxiety risk for ineffective health maintenance' fits, as it ties to coping, not denial , brain infiltration , or disinterest . Nurses in oncology spot this fear fogs learning, needing slower, calmer teaching to stick.
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The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer?
- A. Teach the patient about the seven warning signs of cancer.
- B. Plan to monitor the patient's carcinoembryonic antigen (CEA) level.
- C. Teach the patient about annual chest x-rays for lung cancer screening.
- D. Discuss risks associated with cigarette smoking during each patient encounter.
Correct Answer: D
Rationale: Smoking's the lung cancer kingpin two packs a day screams risk. Hitting the patient with smoking's dangers every visit pushes primary prevention, aiming to cut exposure to tar and carcinogens fueling 85% of cases. Warning signs (CAUTION) and chest x-rays are secondary catching cancer, not stopping it. CEA's a tumor marker for tracking, not prevention. Nurses in oncology know preaching cessation at every chance leverages behavior change, the gold standard to slash lung cancer odds, trumping screening or monitoring in a heavy smoker like this.
A nurse is caring for a client who recently underwent a heart transplant. Which of the following postoperative nursing interventions is the priority?
- A. Maintain strict bedrest
- B. Advance diet as tolerated
- C. Educate the client on medication
- D. Ensure strict adherence to aseptic techniques
Correct Answer: D
Rationale: Heart transplant's success hinges on dodging infection immunosuppression skyrockets risk, making aseptic technique the priority to shield the graft. Bedrest aids early recovery but isn't top. Diet advances slowly, education's vital long-term, but infection's immediate threat trumps. Nurses enforce sterility dressings, lines safeguarding this fragile post-op phase, a life-or-death focus in transplant care.
What is the essence of motivational interviewing?
- A. That change strategies must exactly match the patient's motivation
- B. That behavioural change is impossible if the patient does not want it
- C. That the counsellor motivates the patient to change and increases patient involvement
- D. That the patient's motives to show unhealthy behaviour are systematically analysed
Correct Answer: C
Rationale: Motivational interviewing counsellor sparks, pulls patients in, not rigid matches, impossibles, or motive digs. Nurses roll this, a chronic engagement art.
A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the patient's skin appears yellow. Which blood tests should be done to further explore this clinical sign?
- A. Liver function tests (LFTs)
- B. Complete blood count (CBC)
- C. Platelet count
- D. Blood urea nitrogen and creatinine
Correct Answer: A
Rationale: Yellow skin signals jaundice, often tied to liver dysfunction, a frequent issue post-chemotherapy due to metastatic spread or drug toxicity. Liver function tests (LFTs) like ALT, AST, and bilirubin directly assess liver health, pinpointing if metastases or chemo agents (e.g., hepatotoxic drugs like methotrexate) are at play. A CBC might show anemia or infection but doesn't target liver issues. Platelet count could hint at clotting problems, possibly liver-related, but it's too narrow. Blood urea nitrogen and creatinine check kidney function, not liver, despite both organs handling chemo clearance. Since the liver's a common metastatic site especially from cancers like breast or lung LFTs are the go-to here, guiding the nurse to catch complications early and adjust care, critical in oncology follow-ups.
The pathophysiology of Asthma differs from COPD as:
- A. It is characterised by airflow limitation
- B. There is abnormal inflammatory response to exposure to noxious particles or gases
- C. The airflow limitation is reversible
- D. It is considered an obstructive lung disease
Correct Answer: C
Rationale: Asthma's twist reversible airflow block sets it apart from COPD's fixed choke. Both obstruct, inflame to triggers, but asthma's airways bounce back with puffs. Nurses spot this, a chronic split for treatment.