Nokea
When caring for a patient with a temporary radioactive cervical implant, which action by the student nurse indicates that the unit nurse should intervene?
- A. The student flushes the toilet once after emptying the patient's bedpan.
- B. The student stands by the patient's bed for 30 minutes talking with the patient.
- C. The student places the patient's bedding in the laundry container in the hallway.
- D. The student gives the patient an alcohol-containing mouthwash to use for oral care.
Correct Answer: B
Rationale: Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine or feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.
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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.
External-beam radiation is planned for a patient with endometrial cancer. The nurse teaches the patient which of the following important measures to help prevent complications from the effects of the radiation?
- A. Test all stools for the presence of blood.
- B. Maintain a high-residue, high-fibre diet.
- C. Clean the perianal area carefully after every bowel movement
- D. Inspect the mouth and throat daily for the appearance of thrush.
Correct Answer: C
Rationale: Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.
The nurse is caring for a patient who is receiving chemotherapy for leukemia. The patient's laboratory report shows a neutrophil count of 400/?¼L. Which of the following is the priority nursing intervention?
- A. Administer prescribed antibiotics immediately.
- B. Teach the patient to avoid crowded places.
- C. Assess the patient for signs of bleeding.
- D. Monitor the patient's temperature every 4 hours.
Correct Answer: D
Rationale: A neutrophil count of 400/?¼L indicates severe neutropenia, placing the patient at high risk for infection. Monitoring temperature every 4 hours is the priority to detect early signs of infection. Antibiotics may be needed but only after signs of infection are confirmed. Teaching about avoiding crowds is important but not the immediate priority. Assessing for bleeding is relevant for low platelet counts, not neutropenia.
The nurse is caring for a patient who is a single mother of four school-age children and is hospitalized with metastatic ovarian cancer. The nurse finds the patient crying, and she tells the nurse that she does not know what will happen to her children when she dies. Which of the following is the most appropriate response?
- A. Why don't we talk about the options you have for the care of your children?
- B. Perhaps the children's father will take care of them when you aren't able to.
- C. For now you need to concentrate on getting well, not worry about your children.
- D. Many patients with cancer live for a long time, so it's time to plan for your children.
Correct Answer: A
Rationale: This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning 'Many patients with cancer live for a long time' and 'For now you need to concentrate on getting well' close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's ex-husband will take the children, more assessment information is needed before making plans.
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.