Nokea
The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?
- A. Fatigue related to altered metabolic processes
- B. Altered nutrition: less than body requirements related to anorexia
- C. Risk for infection related to altered immunologic response
- D. Body image disturbance related to weight loss and anorexia
Correct Answer: C
Rationale: HSCT obliterates marrow, tanking immunity risk for infection soars as neutrophils vanish, making it the top nursing diagnosis pre-transplant. Sepsis can kill fast in this window, unlike fatigue or nutrition issues, which matter but aren't immediate threats. Body image might nag later with hair loss or weight shifts, but infection's the killer to watch. Nurses lock in on this, driving strict isolation and monitoring, knowing a stray germ could derail everything in oncology's high-stakes transplant game.
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A general practitioner (GP) advises an overweight patient to go to the gym to work out. Question: This advice is an example of which type of prevention?
- A. Primary prevention
- B. Secondary prevention
- C. Tertiary prevention
- D. Quaternary prevention
Correct Answer: A
Rationale: Gym nudge for overweight primary, stops diabetes before it starts, not screening or late fixes. Nurses push this, a chronic preemptive strike.
The client is admitted for heart failure and has edema, neck vein distension, and ascites. What is the most accurate way to monitor fluid gain or loss in this client?
- A. Auscultate the lungs for crackles or wheezing
- B. Weigh the client daily at the same time with the same scale
- C. Check for pitting edema in the dependent body parts
- D. Assess skin turgor and the condition of mucus membranes
Correct Answer: B
Rationale: Heart failure's fluid dance edema, JVD, ascites needs precise tracking. Daily weights, same time, same scale, catch 1 kg shifts (1 L fluid), the gold standard for gain or loss, outpacing lung sounds' subjectivity. Edema checks or turgor gauge trends, less exact. Nurses weigh in, ensuring diuretic tweaks hit the mark, a reliable ruler in this swollen saga.
Regarding infective endocarditis in an IVDU
- A. Usually presents with fever and respiratory symptoms
- B. Usually involves the mitral valve
- C. The commonest organism is staph epidermidis
- D. Negative blood cultures exclude the diagnosis
Correct Answer: A
Rationale: IVDU endocarditis fever, lung emboli from tricuspid, not mitral, Staph aureus, cultures miss some. Nurses hear this chronic right-side roar.
The nurse is teaching the parents of a 15-year-old who is being treated for acute myelogenous leukemia about the side effects of chemotherapy. For which of the following symptoms should the parents seek medical care immediately?
- A. Earache, stiff neck or sore throat
- B. Blisters, ulcers or a rash appear
- C. A temperature of 101.5 degrees Fahrenheit
- D. Difficulty or pain when swallowing
Correct Answer: C
Rationale: Chemotherapy for acute myelogenous leukemia suppresses the immune system by reducing white blood cell production, leaving the child highly susceptible to infections. A fever of 101.5°F is a critical sign in this context, as it may indicate an infection that, without a functioning immune response, could rapidly progress to sepsis a life-threatening condition. Parents must seek immediate medical care to evaluate and treat the underlying cause, often requiring emergency department intervention. While earache, stiff neck, or sore throat could suggest infection, they are less urgent without fever and may not necessitate immediate action unless severe. Blisters, ulcers, or rashes might reflect chemotherapy side effects like mucositis or drug reactions, manageable with outpatient care unless infected. Difficulty swallowing could stem from mucositis or infection, but fever trumps it in urgency due to its systemic implications. Educating parents to prioritize fever ensures timely intervention, aligning with oncology nursing's focus on preventing complications in immunocompromised pediatric patients.
The nurse caring for oncology clients knows that which form of metastasis is the most common?
- A. Bloodborne
- B. Direct invasion
- C. Lymphatic spread
- D. Via bone marrow
Correct Answer: A
Rationale: Metastasis is the process by which cancer spreads from its original site to distant parts of the body, a critical concern in oncology nursing. Among the various mechanisms, bloodborne metastasis is the most common, as cancer cells often enter the bloodstream and travel to organs like the lungs, liver, or brain. This occurs because the circulatory system provides an efficient pathway for tumor cells to disseminate widely, especially in cancers like breast or lung cancer. Lymphatic spread is also frequent, particularly in carcinomas, where cells travel via lymph nodes, but it is less dominant than bloodborne spread across all cancer types. Direct invasion involves cancer growing into adjacent tissues, which is a local process rather than true metastasis. Bone marrow is not a medium for metastasis but a potential site where cancer can settle, such as in leukemia or multiple myeloma. Understanding that bloodborne metastasis predominates helps nurses prioritize monitoring for systemic symptoms and complications, such as organ dysfunction, in clients with advanced cancer.