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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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The nurse is teaching a client about the signs of infection after chemotherapy. Which of the following should the nurse emphasize?
- A. Frequent urination
- B. Increased thirst
- C. Chills and shaking
- D. Fever over 100.4°F (38°C)
Correct Answer: D
Rationale: In clients undergoing chemotherapy, the immune system is often compromised due to the effects of treatment, making them more susceptible to infections. A fever over 100.4°F (38°C) is considered a critical sign of infection in these patients and requires immediate medical evaluation. Fever may indicate the presence of an infection that could escalate quickly in immunocompromised individuals, so it is vital for patients to recognize this symptom and seek prompt medical attention.
A patient with leukemia has developed stomatitis and is experiencing a nutritional deficit. An oral anesthetic has consequently been prescribed. What health education should the nurse provide to the patient?
- A. Chew with care to avoid inadvertently biting the tongue.
- B. Use the oral anesthetic 1 hour prior to meal time.
- C. Brush teeth before and after eating.
- D. Swallow slowly and deliberately.
Correct Answer: A
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.
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: When a patient experiences alopecia due to chemotherapy, it can significantly impact their self-esteem and body image, particularly in adolescents who are especially sensitive to physical changes. A request for makeup and a wig indicates that the patient is actively taking steps to enhance her appearance and cope with the changes brought on by her treatment. This action reflects a positive engagement with her body image and suggests a desire to feel more comfortable and confident in her appearance, signaling an improvement in her self-esteem.
A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia?
- A. Interrupted sleep pattern
- B. Hot flashes
- C. Epistaxis (nose bleed)
- D. Increased weight
Correct Answer: C
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which increases the risk of bleeding and hemorrhage. Patients receiving chemotherapy agents like carmustine may experience thrombocytopenia as a significant side effect. Epistaxis (nosebleeds) is a common symptom associated with thrombocytopenia, as the blood vessels can become more fragile, and even minor trauma or spontaneous bleeding can occur. Therefore, assessing for signs of bleeding, including epistaxis, is crucial in patients at risk for thrombocytopenia.