Nokea
The nurse is caring for a patient who is receiving chemotherapy for leukemia. The patient's laboratory report shows a neutrophil count of 400/?¼L. Which of the following is the priority nursing intervention?
- A. Administer prescribed antibiotics immediately.
- B. Teach the patient to avoid crowded places.
- C. Assess the patient for signs of bleeding.
- D. Monitor the patient's temperature every 4 hours.
Correct Answer: D
Rationale: A neutrophil count of 400/?¼L indicates severe neutropenia, placing the patient at high risk for infection. Monitoring temperature every 4 hours is the priority to detect early signs of infection. Antibiotics may be needed but only after signs of infection are confirmed. Teaching about avoiding crowds is important but not the immediate priority. Assessing for bleeding is relevant for low platelet counts, not neutropenia.
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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.
When reviewing the chart for a patient with cervical cancer, the nurse notes that the cancer is staged as Tis, N0, M0. Which of the following statements is accurate related to this staging?
- A. The cancer is localized to the cervix.
- B. The cancer cells are well differentiated.
- C. Further testing is needed to determine the spread of the cancer.
- D. It is difficult to determine the original site of the cervical cancer.
Correct Answer: A
Rationale: Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.
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 is caring for a patient with Hodgkin's lymphoma who is undergoing external radiation therapy and tells the nurse, 'I am so tired I can hardly get out of bed in the morning.' Which of the following interventions should the nurse implement?
- A. Minimize activity until the treatment is completed.
- B. Exercise vigorously when fatigue is not as noticeable.
- C. Establish a time to take a short walk almost every day.
- D. Consult with a psychiatrist for treatment of depression.
Correct Answer: C
Rationale: Walking programs are used to keep the patient active without excessive fatigue. Vigorous exercise when the patient is less tired may lead to increased fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility.
A chemotherapeutic agent known to cause alopecia is prescribed for a patient. Which of the following actions should the nurse plan to implement to help maintain the patient's self-esteem?
- A. Suggest that the patient limit social contacts until regrowth of the hair occurs.
- B. Encourage the patient to purchase a wig or hat and wear it once hair loss begins.
- C. Have the patient wash the hair gently with a mild shampoo to minimize hair loss.
- D. Inform the patient that the hair will grow back once the chemotherapy is complete.
Correct Answer: B
Rationale: The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem.