Nokea
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.
You may also like to solve these questions
Which of the following information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider?
- A. Hematocrit of 30%
- B. Platelets of 150 ?? 10^9/L
- C. Hemoglobin of 161 g/L
- D. WBC count of 4 ?? 10^9/L
Correct Answer: D
Rationale: The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapeutic drug dose may need to be lower or that white blood cell (WBC) growth factors such as filgrastim are needed. The other laboratory data do not indicate any immediate life-threatening adverse effects of the chemotherapy.
The nurse is caring for a patient with metastatic renal cell carcinoma who is receiving interleukin-2 (IL-2) as an adjuvant therapy. Which of the following mechanisms of action should the nurse teach the patient about this therapy?
- A. It enhances immunological response to tumour cells.
- B. It stimulates malignant cells in the resting phase to enter mitosis.
- C. It prevents the bone marrow depression caused by chemotherapy.
- D. It protects normal cells from the harmful effects of chemotherapy.
Correct Answer: A
Rationale: IL-2 enhances the ability of the patient's own immune response to suppress tumour cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression.
The nurse is caring for a patient with ovarian cancer who is distressed because her husband rarely visits and tells the nurse, 'He just doesn't care.' The husband indicates to the nurse that 'I never know what to say to help her.' Which of the following nursing diagnoses is most appropriate?
- A. Disabled family coping related to persistently unexpressed feelings by support person
- B. Impaired home maintenance related to insufficient support system
- C. Risk for caregiver role strain as evidenced by increase in care needs
- D. Dysfunctional family processes related to insufficient problem-solving skills
Correct Answer: D
Rationale: The data indicate that this diagnosis is most appropriate because poor communication among the family members is affecting family processes. No data suggest preoccupation with an outside concern as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities.
During a routine health examination, a patient tells the nurse about a family history of colon cancer. Which of the following actions should the nurse take next?
- A. Educate the patient about the need for a colonoscopy at age 50.
- B. Teach the patient how to do home testing for fecal occult blood.
- C. Obtain more information from the patient about the family history.
- D. Schedule a sigmoidoscopy to provide baseline data about the patient.
Correct Answer: C
Rationale: The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning.
The nurse is caring for a patient who is undergoing bone marrow transplantation. Which of the following information should the nurse include in the patient's teaching plan?
- A. Transplant of the donated cells is painful because of the nerves in the tissue lining the bone.
- B. Donor bone marrow cells are transplanted through an incision into the sternum or hip bone.
- C. The transplant procedure takes place in a sterile operating room to minimize the risk for infection.
- D. Hospitalization will be required 2-4 weeks after transplantation.
Correct Answer: D
Rationale: The patient requires strict protective isolation to prevent infection for 2-4 weeks after marrow transplantation while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line, so the transplant is not painful, nor is an operating room or incision required.