Nokea
Use of dental floss is contraindicated in the patient with which of the following assessment findings?
- A. Halitosis
- B. A decreased platelet count
- C. An increased white blood cell count
- D. Xerostomia
Correct Answer: B
Rationale: Use of dental floss is contraindicated in the patient that has a decreased platelet count but otherwise critical to use to enhance oral care. Halitosis, xerostomia, and an increased WBC are not contraindications for the use of dental floss.
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Which of the following findings in a patient who is receiving interleukin-2 indicates a need for rapid action by the nurse?
- A. Generalized muscle aches
- B. Complaints of nausea and anorexia
- C. Oral temperature of 38.1°C (100.6°F)
- D. Capillary leak syndrome with 2+ edema
Correct Answer: D
Rationale: Capillary leak syndrome is a serious adverse effect of interleukin-2 therapy, leading to fluid retention and potential complications like pulmonary edema, requiring immediate intervention. Muscle aches, nausea, and a slightly elevated temperature are common side effects but are less urgent.
A chemotherapeutic agent known to cause alopecia is prescribed for a patient. Which of the following actions should the nurse plan to implement to help maintain the patient's self-esteem?
- A. Suggest that the patient limit social contacts until regrowth of the hair occurs.
- B. Encourage the patient to purchase a wig or hat and wear it once hair loss begins.
- C. Have the patient wash the hair gently with a mild shampoo to minimize hair loss.
- D. Inform the patient that the hair will grow back once the chemotherapy is complete.
Correct Answer: B
Rationale: The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem.
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.
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.
The nurse is caring for a patient with cancer who has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which of the following nursing actions is most appropriate?
- A. Add strained baby meats to foods such as casseroles.
- B. Teach the patient about foods that are high in nutrition.
- C. Avoid giving the patient foods that are strongly disliked.
- D. Put extra spice in the foods that are served to the patient.
Correct Answer: C
Rationale: The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition.