Nokea
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?
- A. Placing cool compresses on the affected arm
- B. Elevating the affected arm on a pillow above heart level
- C. Avoiding arm exercises in the immediate postoperative period
- D. Maintaining an intravenous site below the antecubital area on the affected side
Correct Answer: B
Rationale: After a mastectomy, particularly when lymph nodes are removed, there is an increased risk of lymphedema in the affected arm due to impaired lymphatic drainage. Elevating the affected arm above heart level helps promote lymphatic drainage and reduces the risk of swelling. This intervention facilitates the return of lymph fluid and helps prevent fluid accumulation in the arm.
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A public health nurse has formed an interdisciplinary team that is developing an educational program entitled Cancer: The Risks and What You Can Do About Them. Participants will receive information, but the major focus will be screening for relevant cancers. This program is an example of what type of health promotion activity?
- A. Disease prophylaxis
- B. Risk reduction
- C. Secondary prevention
- D. Tertiary prevention
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?
- A. Fatigue related to altered metabolic processes
- B. Altered nutrition: less than body requirements related to anorexia
- C. Risk for infection related to altered immunologic response
- D. Body image disturbance related to weight loss and anorexia
Correct Answer: C
Rationale: Patients preparing for hematopoietic stem cell transplantation (HSCT) undergo intensive chemotherapy and/or radiation, which significantly suppresses their immune system. This immunosuppression leads to a heightened risk for infection, making it the most critical nursing diagnosis for these patients. As the body's ability to fight off pathogens is compromised, close monitoring and interventions aimed at preventing infections are essential for their safety and recovery.
A nurse knows that the patient with stage 3 based on Ann-arber staging has:
- A. 2 or more lymph node involvement and outside the lymph nodes
- B. 2 or more lymph node involvement on one side of the body
- C. 2 or more lymph nodes on the breasts
- D. 2 or more lymph node involvement on both sides of the body
Correct Answer: D
Rationale: In the Ann Arbor staging system for lymphomas, Stage 3 indicates that the disease has spread beyond the initial lymph node region to involve lymph nodes on both sides of the diaphragm (i.e., the areas above and below the diaphragm). This includes lymphatic involvement in both the thoracic and abdominal regions, signifying a more advanced disease state.
A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate?
- A. Crush the medications if the client cannot swallow them.
- B. Give one medication at a time with a full glass of water.
- C. No special precautions are needed for these medications.
- D. Wear personal protective equipment when handling the medications.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.