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The nurse is teaching a patient who has a new diagnosis of acute leukemia about the complications associated with chemotherapy. The patient is restless and is looking away, never making eye contact. After the teaching, the patient asks the nurse to repeat all of the information. Based on this assessment, which of the following nursing diagnoses is most likely for this patient?
- A. Ineffective denial related to ineffective coping strategies (leukemia diagnosis)
- B. Acute confusion related to pain (infiltration of leukemia cells into the central nervous system)
- C. Anxiety related to threat of death (leukemia diagnosis)
- D. Deficient knowledge (of chemotherapy) related to insufficient interest in learning
Correct Answer: C
Rationale: The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patient's history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiological factors.
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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.
The nurse is caring for a patient who is receiving a vesicant chemotherapeutic agent intravenously. Which of the following actions is most important?
- A. Infuse the medication over a short period of time.
- B. Stop the infusion if swelling is observed at the site.
- C. Administer the chemotherapy through small-bore catheter.
- D. Hold the medication unless a central venous line is available.
Correct Answer: B
Rationale: Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapeutic drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.
When caring for a patient with a temporary radioactive cervical implant, which action by the student nurse indicates that the unit nurse should intervene?
- A. The student flushes the toilet once after emptying the patient's bedpan.
- B. The student stands by the patient's bed for 30 minutes talking with the patient.
- C. The student places the patient's bedding in the laundry container in the hallway.
- D. The student gives the patient an alcohol-containing mouthwash to use for oral care.
Correct Answer: B
Rationale: Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine or feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.
The nurse is preparing a patient for a biopsy of a lump in the right breast and the patient asks the nurse about the difference between a benign tumour and a malignant tumour. Which of the following responses by the nurse is correct?
- A. Benign tumours do not cause damage to other tissues.
- B. Benign tumours are likely to recur in the same location.
- C. Malignant tumours may spread to other tissues or organs.
- D. Malignant cells reproduce more rapidly than normal cells.
Correct Answer: C
Rationale: The major difference between benign and malignant tumours is that malignant tumours invade adjacent tissues and spread to distant tissues and benign tumours never metastasize. The other statements are inaccurate. Both types of tumours may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumours do not usually recur.
When assessing the need for psychological support after the patient has been diagnosed with stage I cancer of the colon, which of the following questions by the nurse will provide the most information?
- A. How long ago were you diagnosed with this cancer?
- B. Do you have any concerns about body image changes?
- C. Can you tell me what has been helpful to you in the past when coping with stressful events?
- D. Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?
Correct Answer: C
Rationale: Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient's need for support. The patient's knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Since surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time.