Nokea
The nurse is caring for a patient with cancer who has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which of the following nursing actions is most appropriate?
- A. Add strained baby meats to foods such as casseroles.
- B. Teach the patient about foods that are high in nutrition.
- C. Avoid giving the patient foods that are strongly disliked.
- D. Put extra spice in the foods that are served to the patient.
Correct Answer: C
Rationale: The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition.
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The nurse is caring for a patient who is receiving chemotherapy for leukemia. Which of the following observations require intervention by the nurse?
- A. The patient ambulates several times a day in the room.
- B. The patient's temperature is 38.2°C (100.8°F).
- C. The patient cleans with a warm washcloth after having a stool.
- D. The patient uses soap and shampoo to shower every other day.
Correct Answer: B
Rationale: Any temperature above 38°C (100.4°F) in a patient receiving chemotherapy should be investigated immediately. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help to prevent skin breakdown and infection.
After the nurse has finished teaching a patient who is scheduled to receive external beam radiation for abdominal cancer about appropriate diet, which dietary selection by the patient indicates that the teaching has been effective?
- A. Fresh fruit salad
- B. Roasted chicken
- C. Whole wheat toast
- D. Cream of potato soup
Correct Answer: B
Rationale: To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products also should be avoided.
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.
A patient with a large stomach tumour that is attached to the liver is scheduled to have a debulking procedure. When teaching the patient, which of the following is the expected outcome of this surgery?
- A. Relief of pain by cutting sensory nerves in the stomach
- B. Control of the tumour growth by removal of malignant tissue
- C. Decrease in tumour size to improve the effects of other therapy
- D. Promotion of better nutrition by relieving the pressure in the stomach
Correct Answer: C
Rationale: A debulking surgery reduces the size of the tumour and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumour growth. The tumour is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs.
External-beam radiation is planned for a patient with endometrial cancer. The nurse teaches the patient which of the following important measures to help prevent complications from the effects of the radiation?
- A. Test all stools for the presence of blood.
- B. Maintain a high-residue, high-fibre diet.
- C. Clean the perianal area carefully after every bowel movement
- D. Inspect the mouth and throat daily for the appearance of thrush.
Correct Answer: C
Rationale: Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.