Nokea
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.
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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.
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.
Which statement by a patient who is scheduled for a needle biopsy of the prostate indicates that the nurse's teaching about the purpose of the biopsy has been effective?
- A. The biopsy will remove the cancer in my prostate gland.
- B. The biopsy will determine how much longer I have to live.
- C. The biopsy will help decide the treatment for my enlarged prostate.
- D. The biopsy will indicate whether the cancer has spread to other organs.
Correct Answer: C
Rationale: A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. Biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life; the three remaining statements indicate a need for patient teaching.
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.
Which of the following nursing actions will be most effective in improving oral intake for a patient with the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers?
- A. Offer the patient frequent small snacks between meals.
- B. Assist the patient to choose favourite foods from the menu.
- C. Provide education about the importance of nutritional intake.
- D. Apply the ordered anaesthetic gel to oral lesions before meals.
Correct Answer: D
Rationale: Since the etiology of the patient's poor nutrition is the painful oral ulcers, the best intervention is to apply anaesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition, but would not be as helpful for this patient.