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: A priority nursing diagnosis for this patient is risk for infection related to altered immunologic response. Because the patients immunity is suppressed, he or she will be at a high risk for infection. The other listed nursing diagnoses are valid, but they are not as high a priority as is risk for infection.
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While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?
- A. Stopping the administration of the drug immediately
- B. Notifying the patients physician
- C. Continuing the infusion but decreasing the rate
- D. Applying a warm compress to the infusion site
Correct Answer: A
Rationale: Doxorubicin hydrochloride is a chemotherapeutic vesicant that can cause severe tissue damage. The nurse should stop the administration of the drug immediately and then notify the patients physician. Ice can be applied to the site once the drug therapy has stopped.
The nurse is describing some of the major characteristics of cancer to a patient who has recently received a diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse should explain differences in which of the following aspects? Select all that apply.
- A. Rate of growth
- B. Ability to cause death
- C. Size of cells
- D. Cell contents
- E. Ability to spread
Correct Answer: A,B,E
Rationale: Benign and malignant cells differ in many cellular growth characteristics, including the method and rate of growth, ability to metastasize or spread, general effects, destruction of tissue, and ability to cause death. Cells come in many sizes, both benign and malignant. Cell contents are basically the same, but they behave differently.
A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem?
- A. The patient requests that her family bring her makeup and wig
- B. The patient begins to discuss the future with her family
- C. The patient reports less disruption from pain and discomfort
- D. The patient cries openly when discussing her disease
Correct Answer: A
Rationale: Requesting her wig and makeup indicates that the patient with alopecia is becoming interested in looking her best and that her body image and self-esteem may be improving. The other options may indicate that other nursing goals are being met, but they do not necessarily indicate improved body image and self-esteem.
You are caring for an adult patient who has developed a mild oral yeast infection following chemotherapy. What actions should you encourage the patient to perform? Select all that apply.
- A. Use a lip lubricant
- B. Scrub the tongue with a firm-bristled toothbrush
- C. Use dental floss every 24 hours
- D. Rinse the mouth with normal saline
- E. Eat spicy food to aid in eradicating the yeast
Correct Answer: A,C,D
Rationale: Stomatitis is an inflammation of the oral cavity. The patient should be encouraged to brush the teeth with a soft toothbrush after meals, use dental floss every 24 hours, rinse with normal saline, and use a lip lubricant. Mouthwashes and hot foods should be avoided.
The nurse is caring for a 39-year-old woman with a family history of breast cancer. She requested a breast tumor marking test and the results have come back positive. As a result, the patient is requesting a bilateral mastectomy. This surgery is an example of what type of oncologic surgery?
- A. Salvage surgery
- B. Palliative surgery
- C. Prophylactic surgery
- D. Reconstructive surgery
Correct Answer: C
Rationale: Prophylactic surgery is used when there is an extensive family history and nonvital tissues are removed. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach. Palliative surgery is performed in an attempt to relieve complications of cancer, such as ulceration, obstruction, hemorrhage, pain, and malignant effusion. Reconstructive surgery may follow curative or radical surgery in an attempt to improve function or obtain a more desirable cosmetic effect.