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: Patients preparing for hematopoietic stem cell transplantation (HSCT) undergo intensive chemotherapy and/or radiation, which significantly suppresses their immune system. This immunosuppression leads to a heightened risk for infection, making it the most critical nursing diagnosis for these patients. As the body's ability to fight off pathogens is compromised, close monitoring and interventions aimed at preventing infections are essential for their safety and recovery.
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Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would the nurse assess first?
- A. Dry, itchy, peeling skin.
- B. Serum calcium of 9.2 mg/dL (2.3 mmol/L).
- C. Serum potassium of 2.8 mEq/L (2.8 mmol/L).
- D. Weight gain of 0.5 lb (1.1 kg) in 1 day.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client with multiple myeloma and is monitoring the client for signs of hypercalcemia. Which symptom would be an early indication?
- A. Polyuria
- B. Polyphagia
- C. Polydipsia
- D. Weight loss
Correct Answer: A
Rationale: In patients with multiple myeloma, hypercalcemia is a common complication due to the release of calcium from the bones as a result of osteolytic lesions. One of the early symptoms of hypercalcemia is polyuria, or increased urine output. This occurs because elevated calcium levels can lead to impaired renal function and increased renal excretion of calcium, which results in increased urine production. Early recognition of polyuria can help prompt further evaluation and management of hypercalcemia, as untreated hypercalcemia can lead to more severe complications.
Which of the following descriptions of chemotherapy is correct?
- A. Chemotherapy is externally given through high energy waves
- B. Chemotherapy is known to have fatigue as a common side effect
- C. Chemotherapy spreads throughout the body
- D. Chemotherapy attacks cancer cells only
Correct Answer: C
Rationale: Chemotherapy drugs are typically administered systemically, meaning they circulate throughout the body via the bloodstream. This allows them to target cancer cells that may have spread beyond the original tumor site, making chemotherapy an effective treatment for cancers that are metastatic (have spread to other parts of the body). However, because chemotherapy is not selective, it can also affect healthy cells that divide rapidly, leading to a range of side effects.
A nurse is preparing health education for a patient who has received a diagnosis of myelodysplastic syndrome (MDS). Which of the following topics should the nurse prioritize?
- A. Techniques for energy conservation and activity management
- B. Emergency management of bleeding episodes
- C. Technique for the administration of bronchodilators by metered-dose inhaler
- D. Techniques for self-palpation of the lymph nodes
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse knows that the patient with stage 3 based on Ann-arber staging has:
- A. 2 or more lymph node involvement and outside the lymph nodes
- B. 2 or more lymph node involvement on one side of the body
- C. 2 or more lymph nodes on the breasts
- D. 2 or more lymph node involvement on both sides of the body
Correct Answer: D
Rationale: In the Ann Arbor staging system for lymphomas, Stage 3 indicates that the disease has spread beyond the initial lymph node region to involve lymph nodes on both sides of the diaphragm (i.e., the areas above and below the diaphragm). This includes lymphatic involvement in both the thoracic and abdominal regions, signifying a more advanced disease state.