Nokea
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.
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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.
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.
Which of the following findings in a patient who is receiving interleukin-2 indicates a need for rapid action by the nurse?
- A. Generalized muscle aches
- B. Complaints of nausea and anorexia
- C. Oral temperature of 38.1°C (100.6°F)
- D. Capillary leak syndrome with 2+ edema
Correct Answer: D
Rationale: Capillary leak syndrome is a serious adverse effect of interleukin-2 therapy, leading to fluid retention and potential complications like pulmonary edema, requiring immediate intervention. Muscle aches, nausea, and a slightly elevated temperature are common side effects but are less urgent.
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.
Use of dental floss is contraindicated in the patient with which of the following assessment findings?
- A. Halitosis
- B. A decreased platelet count
- C. An increased white blood cell count
- D. Xerostomia
Correct Answer: B
Rationale: Use of dental floss is contraindicated in the patient that has a decreased platelet count but otherwise critical to use to enhance oral care. Halitosis, xerostomia, and an increased WBC are not contraindications for the use of dental floss.