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When reviewing the client’s medical record, the experienced nurse discovers that the client’s breast cancer is staged as T4 N3 M1. Which comment made by the experienced nurse to the new nurse is correct?
- A. “This client has a 3-cm breast tumor that has spread to only one lymph node.”
- B. “The TNM system is used to classify solid tumors by size and degree of spread.”
- C. “The higher the number in the TNM system, the better the chances are for a cure.”
- D. “This TNM system helps to classify tumors as either well- or poorly differentiated.”
Correct Answer: B
Rationale: A. The T4 N3 M1 indicates that the client’s primary tumor is very large, involves 3 lymph nodes, with distant metastasis (T is the size and extent and ranges from 1-4; N is number of nodes involved, and M1 indicates metastasis). B. This statement is correct. The tumor-node-metastasis (TNM) system classifies solid tumors by size and degree of spread. It is an international system that allows comparison of statistics among cancer centers. C. A higher number means that a more serious situation exists. D. A different rating system is used to define the cell types of tumors as well differentiated (closely resembles normal tissue) or poorly differentiated (tumor that contains some normal cells, but most cells are abnormal).
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The nurse is admitting a 24-year-old African American female client with a diagnosis of rule-out anemia. The client has a history of gastric bypass surgery for obesity four (4) years ago. Current assessment findings include height 5’5”; weight 75 kg; P 110, R 27, and BP 104/66; pale mucous membranes and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed?
- A. Vitamin B12 deficiency.
- B. Folic acid deficiency.
- C. Iron deficiency.
- D. Sickle cell anemia.
Correct Answer: A
Rationale: Gastric bypass impairs B12 absorption, causing B12 deficiency anemia (A) with pale membranes, tachycardia, and dyspnea. Folic acid (B) is less likely, iron (C) is possible but secondary, and sickle cell (D) is genetic.
Which statement made by the parent of a child newly diagnosed with sickle cell anemia indicates a need for more teaching?
- A. We are going to the mountains for our vacation this year.'
- B. It's a good thing she likes to drink juices.'
- C. If she needs something for pain, I will give her baby acetaminophen.'
- D. I will make sure that she doesn't get chilled when it is cold outside.'
Correct Answer: A
Rationale: High altitudes, like mountains, have lower oxygen levels, which can precipitate a sickle cell crisis, indicating a need for more teaching. Drinking juices, using acetaminophen, and avoiding chills are appropriate.
In which order should the nurse address the assessment findings for the client who has undergone a total laryngectomy? Place the findings in the order of priority.
- A. Copious oral secretions and nasal mucus draining from the nose
- B. Restless and has a mucus plug in the tracheostomy
- C. NG tube used for intermittent feedings pulled halfway out
- D. Oozing serosanguineous drainage around the tracheostomy tube and dressing saturated
Correct Answer: B, A, D, C
Rationale: . Restless and has a mucus plug in the tracheostomy is priority requiring immediate attention due to the negative impact on air exchange. The client needs immediate suctioning. A. Copious oral secretions and nasal mucus draining from the nose should be next. After a total laryngectomy the mouth does not communicate with the trachea, so copious oral secretions and nasal drainage would not influence air exchange, but these create a source of discomfort for the client. D. Oozing serosanguineous drainage around the tracheostomy tube and saturated dressing should be addressed third. Changing the dressing now would allow the nurse to inspect the site and ensure tube patency. C. NG tube used for intermittent feedings pulled halfway out can be addressed last. There is no indication that a tube feeding is infusing. The HCP should be contacted to reinsert the NG tube to prevent disruption of the suture line in the esophagus.
The nurse is discussing dietary sources of iron with a client who has iron deficiency anemia. Which menu, if selected by the client, indicates the best understanding of the diet?
- A. Milkshake, hot dog, and beets
- B. Beef steak, spinach, and grape juice
- C. Chicken salad, green peas, and coffee
- D. Macaroni and cheese, coleslaw, and lemonade
Correct Answer: B
Rationale: Beef, spinach, and grape juice contain iron. Milk contains no iron, and the other options have lower iron content.
A child with leukemia bruises easily. This is most likely due to which of the following?
- A. Decreased fibrinogen levels
- B. Excessive clotting elsewhere in the body
- C. Decreased platelets
- D. Decreased erythrocytes
Correct Answer: C
Rationale: Leukemia causes bone marrow failure, leading to decreased platelets, which results in easy bruising.