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Which of the following information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider?
- A. Hematocrit of 30%
- B. Platelets of 150 ?? 10^9/L
- C. Hemoglobin of 161 g/L
- D. WBC count of 4 ?? 10^9/L
Correct Answer: D
Rationale: The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapeutic drug dose may need to be lower or that white blood cell (WBC) growth factors such as filgrastim are needed. The other laboratory data do not indicate any immediate life-threatening adverse effects of the chemotherapy.
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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 intravesical bladder chemotherapy. Which of the following adverse effects should the nurse monitor for in this patient?
- A. Nausea
- B. Alopecia
- C. Mucositis
- D. Hematuria
Correct Answer: D
Rationale: The adverse effects of intravesical chemotherapy are confined to the bladder. The other adverse effects are associated with systemic chemotherapy.
The nurse is caring for a patient with ovarian cancer who is distressed because her husband rarely visits and tells the nurse, 'He just doesn't care.' The husband indicates to the nurse that 'I never know what to say to help her.' Which of the following nursing diagnoses is most appropriate?
- A. Disabled family coping related to persistently unexpressed feelings by support person
- B. Impaired home maintenance related to insufficient support system
- C. Risk for caregiver role strain as evidenced by increase in care needs
- D. Dysfunctional family processes related to insufficient problem-solving skills
Correct Answer: D
Rationale: The data indicate that this diagnosis is most appropriate because poor communication among the family members is affecting family processes. No data suggest preoccupation with an outside concern as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities.
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 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.