Nokea
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.
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A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best?
- A. Explain the pathophysiologic reasons behind the client not eating.
- B. Help the family show other ways to demonstrate love and caring.
- C. Suggest foods and liquids the client might be willing to try to eat.
- D. Tell the family the client isn't able to eat now no matter what they bring.
Correct Answer: B
Rationale: The best action for the nurse in this situation is to help the family show other ways to demonstrate love and caring. When a client with cancer is experiencing anorexia and mucositis, it can be challenging for them to eat even their favorite foods. By assisting the family in finding alternative ways to provide comfort and care, the nurse can help create a supportive environment for the client. Option A is not the best choice as explaining the pathophysiologic reasons may not address the emotional needs of the client and family. Option C, suggesting foods and liquids, might not be helpful if the client is unable to tolerate them due to their condition. Option D, telling the family that the client can't eat, may come across as dismissive and not supportive of the family's concerns.
Nurse Mike is providing care to a client with chronic myelogenous leukemia (CML). The nurse knows that the client is at risk for tumor lysis syndrome. Which of the following laboratory values requires immediate intervention?
- A. Increased uric acid level
- B. Increased serum potassium level
- C. Increased serum sodium level
- D. Increased fibrinogen level
Correct Answer: A
Rationale: The correct answer is A: Increased uric acid level. In tumor lysis syndrome, rapid cell destruction releases large amounts of potassium, phosphate, and nucleic acids into the bloodstream. Uric acid can accumulate rapidly, leading to hyperuricemia, which can result in kidney damage due to urate crystal deposition. Immediate intervention is necessary to prevent renal complications. Choices B, C, and D are incorrect because while electrolyte imbalances are common in tumor lysis syndrome, hyperuricemia with potential kidney damage is the priority concern that requires immediate attention.
Which of the following management strategies is not included for a patient taking chemotherapeutic drugs?
- A. Limit exposure of pregnant visitors
- B. Protect client from infection
- C. Allow client to use makeup and wig
- D. Administer IV fluids as ordered
Correct Answer: C
Rationale: The correct answer is C. Chemotherapy can lead to hair loss, and while using wigs is common, it is not a primary management strategy. The focus should be on limiting exposure to pregnant visitors to prevent harm to the fetus, protecting the client from infections due to a compromised immune system, and administering IV fluids as ordered to maintain hydration levels. Allowing the client to use makeup and wigs is not a primary concern when managing a patient taking chemotherapeutic drugs.
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.
A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy?
- A. Administer an antiemetic.
- B. Administer an antimetabolite.
- C. Administer a tumor antibiotic.
- D. Administer an anticoagulant.
Correct Answer: A
Rationale: The correct answer is A: Administer an antiemetic. Chemotherapy commonly causes nausea and vomiting as adverse effects. Antiemetics are medications specifically used to prevent or treat these symptoms. Choices B, C, and D are incorrect because administering an antimetabolite, a tumor antibiotic, or an anticoagulant would not directly address the most common adverse effects of chemotherapy, which are nausea and vomiting.