Nokea
When assessing the need for psychological support after the patient has been diagnosed with stage I cancer of the colon, which of the following questions by the nurse will provide the most information?
- A. How long ago were you diagnosed with this cancer?
- B. Do you have any concerns about body image changes?
- C. Can you tell me what has been helpful to you in the past when coping with stressful events?
- D. Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?
Correct Answer: C
Rationale: Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient's need for support. The patient's knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Since surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time.
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After the nurse has finished teaching a patient who is scheduled to receive external beam radiation for abdominal cancer about appropriate diet, which dietary selection by the patient indicates that the teaching has been effective?
- A. Fresh fruit salad
- B. Roasted chicken
- C. Whole wheat toast
- D. Cream of potato soup
Correct Answer: B
Rationale: To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products also should be avoided.
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.
The nurse is caring for a patient who is receiving chemotherapy for leukemia. Which of the following observations require intervention by the nurse?
- A. The patient ambulates several times a day in the room.
- B. The patient's temperature is 38.2°C (100.8°F).
- C. The patient cleans with a warm washcloth after having a stool.
- D. The patient uses soap and shampoo to shower every other day.
Correct Answer: B
Rationale: Any temperature above 38°C (100.4°F) in a patient receiving chemotherapy should be investigated immediately. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help to prevent skin breakdown and infection.
The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which of the following snack choices by the patient indicates that the teaching has been effective?
- A. Orange sherbet
- B. Fresh fruit salad
- C. Strawberry yogurt
- D. Cream cheese bagel
Correct Answer: C
Rationale: Yogurt has high biological value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Orange sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein.
The nurse is caring for a patient who is receiving a vesicant chemotherapeutic agent intravenously. Which of the following actions is most important?
- A. Infuse the medication over a short period of time.
- B. Stop the infusion if swelling is observed at the site.
- C. Administer the chemotherapy through small-bore catheter.
- D. Hold the medication unless a central venous line is available.
Correct Answer: B
Rationale: Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapeutic drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.