Professional Documents
Culture Documents
1. The newly admitted client has burns on both legs. The burned areas appear white
and leather-like. No blisters or bleeding are present, and the client states that he or
she has little pain. How should this injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
ANS: D
The characteristics of the wound meet the criteria for a full-thickness injury (color
that is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm
and inelastic).
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological
Integrity;
2. The newly admitted client has a large burned area on the right arm. The burned
area appears red, has blisters, and is very painful. How should this injury be
categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
ANS: B
The characteristics of the wound meet the criteria for a superficial partial thickness
injury (color that is pink or red; blisters; pain present and high).
3. The burned client newly arrived from an accident scene is prescribed to receive 4
mg of morphine sulfate by IV push. What is the most important reason to administer
the opioid analgesic to this client by the intravenous route?
ANS: C
Although providing some pain relief has a high priority, and giving the drug by the
IV route instead of IM, SC, or orally does increase the rate of effect, the most
important reason is to prevent an overdose from accumulation of drug in the
interstitial space during the fluid shift of the emergent phase. When edema is
present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This
delayed absorption can result in lethal blood levels of analgesics.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;
4. Which vitamin deficiency is most likely to be a long-term consequence of a fullthickness burn injury?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
ANS: D
Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the
activation of vitamin D. Activation of vitamin D is lost completely in fullthickness
burns.
DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Health Promotion and Maintenance
5. Which client factors should alert the nurse to potential increased complications
with a burn injury?
ANS: C
Burns of the perineum increase the risk for sepsis. Burns of the hands require
special attention to ensure the best functional outcome.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity/Safe, Effective Care
Environment;
D. To inhibit loss of fluid from the circulatory system and prevent hypovolemic
shock.
ANS: C
Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn
as a result of increased hydrochloric acid production and decreased mucosal barrier.
Cimetidine inhibits the production and release of hydrochloric acid.
7. At what point after a burn injury should the nurse be most alert for the
complication of hypokalemia?
ANS: C
Hypokalemia is most likely to occur during the fluid remobilization period as a result
of dilution, potassium movement back into the cells, and increased potassium
excreted into the urine with the greatly increased urine output.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;
8. What clinical manifestation should alert the nurse to possible carbon monoxide
poisoning in a client who experienced a burn injury during a house fire?
ANS: C
The saturation of hemoglobin molecules with carbon monoxide and the subsequent
vasodilation induces a cherry red color of the mucous membranes in these clients.
The other manifestations are associated with inhalation injury, but not specifically
carbon monoxide poisoning.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological
Integrity;
ANS: C
Circumferential eschar can act as a tourniquet when edema forms from the fluid
shift, increasing tissue pressure and preventing blood flow to the distal extremities
and increasing the risk for tissue necrosis. This problem is an emergency and,
without intervention, can lead to loss of the distal limb. This problem can be
reduced or corrected with an escharotomy.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Evaluation
10. What additional laboratory test should be performed on any African American
client who sustains a serious burn injury?
A. Total protein
B. Tissue type antigens
C. Prostate specific antigen
D. Hemoglobin S electrophoresis
ANS: D
Sickle cell disease and sickle cell trait are more common among African Americans.
Although clients with sickle cell disease usually know their status, the client with
sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur
in the emergent phase of a burn injury could result in decreased tissue perfusion
that is sufficient to cause sickling of cells, even in a person who only has the trait.
Determining the clients sickle cell status by checking the percentage of hemoglobin
S is essential for any African American client who has a burn injury.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and
Maintenance;
11. Which type of fluid should the nurse expect to prepare and administer as fluid
resuscitation during the emergent phase of burn recovery?
A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells
ANS: B
Although not universally true, most fluid resuscitation for burn injuries starts with
crystalloid solutions, such as normal saline and Ringers lactate. The burn client
rarely requires blood during the emergent phase unless the burn is complicated by
another injury that involved hemorrhage. Colloids and plasma are not generally
used during the fluid shift phase because these large particles pass through the
leaky capillaries into the interstitial fluid, where they increase the osmotic pressure.
Increased osmotic pressure in the interstitial fluid can worsen the capillary leak
syndrome and make maintaining the circulating fluid volume even more difficult.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;
12. The client with a dressing covering the neck is experiencing some respiratory
difficulty. What is the nurses best first action?
A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.
ANS: B
Respiratory difficulty can arise from external pressure. The first action in this
situation would be to loosen the dressing and then reassess the client's respiratory
status.
13. The client who experienced an inhalation injury 6 hours ago has been wheezing.
When the client is assessed, wheezes are no longer heard. What is the nurses best
action?
ANS: B
Clients with severe inhalation injuries may sustain such progressive obstruction that
they may lose effective movement of air. When this occurs, wheezing is no longer
heard and neither are breath sounds. The client requires the establishment of an
emergency airway and the swelling usually precludes intubation.
14. Ten hours after the client with 50% burns is admitted, her blood glucose level is
90 mg/dL. What is the nurses best action?
ANS: B
Neural and hormonal compensation to the stress of the burn injury in the emergent
phase increases liver glucose production and release. An acute rise in the blood
glucose level is an expected client response and is helpful in the generation of
energy needed for the increased metabolism that accompanies this trauma.
15. On admission to the emergency department the burned client's blood pressure
is 90/60, with an apical pulse rate of 122. These findings are an expected result of
what thermal injuryrelated response?
A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning
ANS: A
Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage
is unusual in a burn injury. The physiologic effect of histamine release in injured
tissues is a loss of vascular volume to the interstitial space, with a resulting
decrease in blood pressure.
16. Twelve hours after the client was initially burned, bowel sounds are absent in all
four abdominal quadrants. What is the nurses best action?
17. Which clinical manifestation indicates that the burned client is moving into the
fluid remobilization phase of recovery?
ANS: A
The fluid remobilization phase improves renal blood flow, increasing diuresis and
restoring fluid and electrolyte levels. The increased water content of the urine
reduces its specific gravity.
18. What is the priority nursing diagnosis during the first 24 hours for a client with
full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left
arm?
ANS: C
During the emergent phase, fluid shifts into interstitial tissue in burned areas. When
the burn is circumferential on an extremity, the swelling can compress blood vessels
to such an extent that circulation is impaired distal to the injury, necessitating the
intervention of an escharotomy. Chemical burns do not cause inhalation injury.
19. All of the following laboratory test results on a burned client's blood are present
during the emergent phase. Which result should the nurse report to the physician
immediately?
ANS: B
All these findings are abnormal; however, only the serum potassium level is
changed to the degree that serious, life-threatening responses could result. With
such a rapid rise in the potassium level, the client is at high risk for experiencing
severe cardiac dysrhythmias and death.
20. The client has experienced an electrical injury, with the entrance site on the left
hand and the exit site on the left foot. What are the priority assessment data to
obtain from this client on admission?
A. Airway patency
B. Heart rate and rhythm
C. Orientation to time, place, and person
D. Current range of motion in all extremities
ANS: B
The airway is not at any particular risk with this injury. Electric current travels
through the body from the entrance site to the exit site and can seriously damage
all tissues between the two sites. Early cardiac damage from electrical injury
includes irregular heart rate, rhythm, and ECG changes.
21. In assessing the client's potential for an inhalation injury as a result of a flame
burn, what is the most important question to ask the client on admission?
ANS: D
The risk for inhalation injury is greatest when flame burns occur indoors in small,
poorly ventilated rooms. although smoking increases the risk for some problems, it
does not predispose the client for an inhalation injury.
22. Which information obtained by assessment ensures that the client's respiratory
efforts are currently adequate?
ANS: C
Clients may have ineffective respiratory efforts and gas exchange even though they
are able to talk, have good respiratory movement, and are alert. The best indicator
for respiratory effectiveness is the maintenance of oxygen saturation within the
normal range.
23. Which information obtained by assessment ensures that the client's respiratory
efforts are currently adequate?
ANS: C
Clients may have ineffective respiratory efforts and gas exchange even though they
are able to talk, have good respiratory movement, and are alert. The best indicator
for respiratory effectiveness is the maintenance of oxygen saturation within the
normal range.
24. The burned client's family ask at what point the client will no longer be at
increased risk for infection. What is the nurses best response?
ANS: B
Intact skin is a major barrier to infection and other disruptions in homeostasis. No
matter how much time has passed since the burn injury, the client remains at great
risk for infection as long as any area of skin is open.
25. The burned client relates the following history of previous health problems.
Which one should alert the nurse to the need for alteration of the fluid resuscitation
plan?
A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month
ANS: C
It is likely the client has a diminished cardiac output as a result of the old MI and
would be at greater risk for the development of congestive heart failure and
pulmonary edema during fluid resuscitation.
26. The burned client on admission is drooling and having difficulty swallowing.
What is the nurses best first action?
ANS: C
Difficulty swallowing and drooling are indications of oropharyngeal edema and can
precede pulmonary failure. The clients airway is in severe jeopardy and intubation
is highly likely to be needed shortly.
27. Which intervention is most important for the nurse to use to prevent infection by
cross-contamination in the client who has open burn wounds?
ANS: A
Cross-contamination occurs when microorganisms from another person or the
environment are transferred to the client. Although all the interventions listed above
can help reduce the risk for infection, only handwashing can prevent
crosscontamination.
28. In reviewing the burned client's laboratory report of white blood cell count with
differential, all the following results are listed. Which laboratory finding indicates the
possibility of sepsis?
ANS: C
Normally, the mature segmented neutrophils (segs) are the major population of
circulating leukocytes, constituting 55% to 70% of the total white blood count.
Fewer than 3% to 5% of the circulating white blood cells should be the less mature
band neutrophils. A left shift occurs when the bone marrow releases more
immature neutrophils than mature neutrophils. Such a shift indicates severe
infection or sepsis, in which the clients immune system cannot keep pace with the
infectious process.
29. The client has a deep partial-thickness injury to the posterior neck. Which
intervention is most important to use during the acute phase to prevent
contractures associated with this injury?
ANS: C
The function that would be disrupted by a contracture to the posterior neck is
flexion. Moving the head from side to side prevents such a loss of flexion.
30. The client has severe burns around the right hip. Which position is most
important to be emphasized by the nurse that the client maintain to retain
maximum function of this joint?
ANS: D
Maximum function for ambulation occurs when the hip and leg are maintained at
full extension with neutral rotation. Although the client does not have to spend 24
hours at a time in this position, he or she should be in this position (in bed or
standing) more of the time than with the hip in any degree of flexion.
31. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic)
to the burn before dressing the wound. The client has all the following
manifestations. Which manifestation indicates that the client is having an adverse
reaction to this topical agent?
ANS: D
Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the
wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin
is nephrotoxic and sufficient amounts can be absorbed through burn wounds to
affect kidney function. Any client receiving gentamicin by any route should have
kidney function monitored.
32. The client, who is 2 weeks postburn with a 40% deep partial-thickness injury,
still has open wounds. On taking the morning vital signs, the client is found to have
a below-normal temperature, is hypotensive, and has diarrhea. What is the nurses
best action?
A. Nothing, because the findings are normal for clients during the acute phase of
recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the clients airway and oxygen saturation.
D. Notify the burn emergency team.
ANS: D
These findings are associated with systemic gram-negative infection and sepsis.
This is a medical emergency and requires prompt attention.
A. Changing gloves between wound care on different parts of the client's body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.
ANS: A
Autocontamination is the transfer of microorganisms from one area to another area
of the same client's body, causing infection of a previously uninfected area.
Although all techniques listed can help reduce the risk for infection, only changing
gloves between carrying out wound care on difference parts of the clients body can
prevent autocontamination.
34. When should ambulation be initiated in the client who has sustained a major
burn?
A. When all full-thickness areas have been closed with skin grafts
B. When the client's temperature has remained normal for 24 hours
C. As soon as possible after wound debridement is complete
D. As soon as possible after resolution of the fluid shift
ANS: D
Regular, progressive ambulation is initiated for all burn clients who do not have
contraindicating concomitant injuries as soon as the fluid shift resolves. Clients can
be ambulated with extensive dressings, open wounds, and nearly any type of
attached lines, tubing, and other equipment.
35. What statement by the client indicates the need for further discussion regarding
the outcome of skin grafting (allografting) procedures?
A. For the first few days after surgery, the donor sites will be painful.
B. Because the graft is my own skin, there is no chance it won't 'take'.
C. I will have some scarring in the area when the skin is removed for grafting.
D. Once all grafting is completed, my risk for infection is the same as it was
before I was burned.
ANS: B
Factors other than tissue type, such as circulation and infection, influence whether
and how well a graft takes. The client should be prepared for the possibility that
not all grafting procedures will be successful.
ANS: D
Although a return to preburn functional levels is rarely possible, burned clients are
considered fully recovered or rehabilitated when they have achieved their highest
possible level of physical, social, and emotional functioning.
37. Which statement made by the client with facial burns who has been prescribed
to wear a facial mask pressure garment indicates correct understanding of the
purpose of this treatment?
ANS: D
The purpose of wearing the pressure garment over burn injuries for up to 1 year is
to prevent hypertrophic scarring and contractures from forming. Scars will still be
present. Although the mask does provide protection of sensitive newly healed skin
and grafts from sun exposure, this is not the purpose of wearing the mask. The
pressure garment will not change the angle of ear attachment to the head.
38. What is the priority nursing diagnosis for a client in the rehabilitative phase of
recovery from a burn injury?
A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements
ANS: B
Recovery from a burn injury requires a lot of work on the part of the client and
significant others. Seldom is the client restored to the preburn level of functioning.
Adjustments to changes in appearance, family structure, employment opportunities,
role, and functional limitations are only a few of the numerous life-changing
alterations that must be made or overcome by the client. By the rehabilitation
phase, acute pain from the injury or its treatment is no longer a problem.
2. Nurse Meredith is instructing a premenopausal woman about breast selfexamination. The nurse should tell the client to do her self-examination:
3. Nurse Kent is teaching a male client to perform monthly testicular selfexaminations. Which of the following points would be appropriate to make?
a. Immediately
b. 1 week
c. 2 to 3 weeks
d. 1 month
Answer C. Chlorambucil-induced alopecia occurs 2 to 3 weeks after therapy begins.
6. The nurse is instructing the 35 year old client to perform a testicular selfexamination. The nurse tells the client:
a. Monitoring temperature
b. Ambulation three times daily
c. Monitoring the platelet count
d. Monitoring for pathological fractures
Answer C. Thrombocytopenia indicates a decrease in the number of platelets in the
circulating blood. A major concern is monitoring for and preventing bleeding. Option
9. Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy.
The nurse avoids which of the following in the care of this client?
10. Mina, who is suspected of an ovarian tumor is scheduled for a pelvic ultrasound.
The nurse provides which preprocedure instruction to the client?
11. A male client is diagnosed as having a bowel tumor and several diagnostic tests
are prescribed. The nurse understands that which test will confirm the diagnosis of
malignancy?
12. A female client diagnosed with multiple myeloma and the client asks the nurse
about the diagnosis. The nurse bases the response on which description of this
disorder?
13. Nurse Bea is reviewing the laboratory results of a client diagnosed with multiple
myeloma. Which of the following would the nurse expect to note specifically in this
disorder?
a. Increased calcium
b. Increased white blood cells
c. Decreased blood urea nitrogen level
d. Decreased number of plasma cells in the bone marrow
Answer A. Findings indicative of multiple myeloma are an increased number of
plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of
calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen
level. An increased white blood cell count may or may not be present and is not
related specifically to multiple myeloma.
a. Alopecia
b. Back pain
c. Painless testicular swelling
d. Heavy sensation in the scrotum
Answer A. Alopecia is not an assessment finding in testicular cancer. Alopecia may
occur, however, as a result of radiation or chemotherapy. Options B, C, and D are
assessment findings in testicular cancer. Back pain may indicate metastasis to the
retroperitoneal lymph nodes.
15. The male client is receiving external radiation to the neck for cancer of the
larynx. The most likely side effect to be expected is:
a. Dyspnea
b. Diarrhea
c. Sore throat
d. Constipation
Answer C. In general, only the area in the treatment field is affected by the
radiation. Skin reactions, fatigue, nausea, and anorexia may occur with radiation to
any site, whereas other side effects occur only when specific areas are involved in
treatment. A client receiving radiation to the larynx is most likely to experience a
sore throat. Options B and D may occur with radiation to the gastrointestinal tract.
Dyspnea may occur with lung involvement.
16. Nurse Joy is caring for a client with an internal radiation implant. When caring
for the client, the nurse should observe which of the following principles?
17. A cervical radiation implant is placed in the client for treatment of cervical
cancer. The nurse initiates what most appropriate activity order for this client?
a. Bed rest
b. Out of bed ad lib
c. Out of bed in a chair only
d. Ambulation to the bathroom only
Answer A. The client with a cervical radiation implant should be maintained on bed
rest in the dorsal position to prevent movement of the radiation source. The head of
the bed is elevated to a maximum of 10 to 15 degrees for comfort. The nurse avoids
turning the client on the side. If turning is absolutely necessary, a pillow is placed
between the knees and, with the body in straight alignment, the client is logrolled.
19. The nurse is caring for a female client experiencing neutropenia as a result of
chemotherapy and develops a plan of care for the client. The nurse plans to:
20. The home health care nurse is caring for a male client with cancer and the client
is complaining of acute pain. The appropriate nursing assessment of the clients
pain would include which of the following?
21. Nurse Mickey is caring for a client who is postoperative following a pelvic
exenteration and the physician changes the clients diet from NPO status to clear
liquids. The nurse makes which priority assessment before administering the diet?
a. Bowel sounds
b. Ability to ambulate
c. Incision appearance
d. Urine specific gravity
Answer A. The client is kept NPO until peristalsis returns, usually in 4 to 6 days.
When signs of bowel function return, clear fluids are given to the client. If no
distention occurs, the diet is advanced as tolerated. The most important
assessment is to assess bowel sounds before feeding the client. Options B, C, and D
are unrelated to the subject of the question.
22. A male client is admitted to the hospital with a suspected diagnosis of Hodgkins
disease. Which assessment findings would the nurse expect to note specifically in
the client?
a. Fatigue
b. Weakness
c. Weight gain
d. Enlarged lymph nodes
Answer D. Hodgkins disease is a chronic progressive neoplastic disorder of
lymphoid tissue characterized by the painless enlargement of lymph nodes with
progression to extralymphatic sites, such as the spleen and liver. Weight loss is
most likely to be noted. Fatigue and weakness may occur but are not related
significantly to the disease.
23. During the admission assessment of a 35 year old client with advanced ovarian
cancer, the nurse recognizes which symptom as typical of the disease?
a. Diarrhea
b. Hypermenorrhea
c. Abdominal bleeding
d. Abdominal distention
Answer D. Clinical manifestations of ovarian cancer include abdominal distention,
urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure
caused by the growing tumor and the effects of urinary or bowel obstruction,
constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal
bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.
24. Nurse Kate is reviewing the complications of colonization with a client who has
microinvasive cervical cancer. Which complication, if identified by the client,
indicates a need for further teaching?
a. Infection
b. Hemorrhage
c. Cervical stenosis
d. Ovarian perforation
Answer D. Conization procedure involves removal of a cone-shaped area of the
cervix. Complications of the procedure include hemorrhage, infection, and cervical
stenosis. Ovarian perforation is not a complication.
25. Mr. Miller has been diagnosed with bone cancer. You know this type of cancer is
classified as:
a. sarcoma.
b. lymphoma.
c. carcinoma.
d. melanoma.
Answer A. Tumors that originate from bone,muscle, and other connective tissue are
called sarcomas.
26. Sarah, a hospice nurse visits a client dying of ovarian cancer. During the visit,
the client expresses that If I can just live long enough to attend my daughters
graduation, Ill be ready to die. Which phrase of coping is this client experiencing?
a. Anger
b. Denial
c. Bargaining
d. Depression
Answer C. Denial, bargaining, anger, depression, and acceptance are recognized
stages that a person facing a life-threatening illness experiences. Bargaining
identifies a behavior in which the individual is willing to do anything to avoid loss or
change prognosis or fate. Denial is expressed as shock and disbelief and may be the
first response to hearing bad news. Depression may be manifested by hopelessness,
weeping openly, or remaining quiet or withdrawn. Anger also may be a first
response to upsetting news and the predominant theme is why me? or the
blaming of others.
27. Nurse Farah is caring for a client following a mastectomy. Which assessment
finding indicates that the client is experiencing a complication related to the
surgery?
28. The nurse is admitting a male client with laryngeal cancer to the nursing unit.
The nurse assesses for which most common risk factor for this type of cancer?
a. Alcohol abuse
b. Cigarette smoking
c. Use of chewing tobacco
d. Exposure to air pollutants
Answer B. The most common risk factor associated with laryngeal cancer is
cigarette smoking. Heavy alcohol use and the combined use of tobacco increase the
risk. Another risk factor is exposure to environmental pollutants.
29. The female client who has been receiving radiation therapy for bladder cancer
tells the nurse that it feels as if she is voiding through the vagina. The nurse
interprets that the client may be experiencing:
30. The client with leukemia is receiving busulfan (Myleran) and allopurinol
(Zyloprim). The nurse tells the client that the purpose if the allopurinol is to prevent:
a. Nausea
b. Alopecia
c. Vomiting
d. Hyperuricemia
Answer D. Allopurinol decreases uric acid production and reduces uric acid
concentrations in serum and urine. In the client receiving chemotherapy, uric acid
levels increase as a result of the massive cell destruction that occurs from the
chemotherapy. This medication prevents or treats hyperuricemia caused by
chemotherapy. Allopurinol is not used to prevent alopecia, nausea, or vomiting.
2. For a female client with newly diagnosed cancer, the nurse formulates a nursing
diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis.
Which expected outcome would be appropriate for this client?
3. A male client with a cerebellar brain tumor is admitted to an acute care facility.
The nurse formulates a nursing diagnosis of Risk for injury. Which related-to
phrase should the nurse add to complete the nursing diagnosis statement?
4. A female client with cancer is scheduled for radiation therapy. The nurse knows
that radiation at any treatment site may cause a certain adverse effect. Therefore,
the nurse should prepare the client to expect:
a. hair loss.
b. stomatitis.
c. fatigue.
d. vomiting.
Answer C. Radiation therapy may cause fatigue, skin toxicities, and anorexia
regardless of the treatment site. Hair loss, stomatitis, and vomiting are site-specific,
not generalized, adverse effects of radiation therapy.
5. Nurse April is teaching a client who suspects that she has a lump in her breast.
The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
a. breast self-examination.
b. mammography.
c. fine needle aspiration.
d. chest X-ray.
Answer C. Fine needle aspiration and biopsy provide cells for histologic examination
to confirm a diagnosis of cancer. A breast self-examination, if done regularly, is the
most reliable method for detecting breast lumps early. Mammography is used to
detect tumors that are too small to palpate. Chest X-rays can be used to pinpoint rib
metastasis.
a. cancerous lumps.
b. areas of thickness or fullness.
c. changes from previous self-examinations.
d. fibrocystic masses.
Answer C. Women are instructed to examine themselves to discover changes that
have occurred in the breast. Only a physician can diagnose lumps that are
cancerous, areas of thickness or fullness that signal the presence of a malignancy,
or masses that are fibrocystic as opposed to malignant.
9. A client, age 41, visits the gynecologist. After examining her, the physician
suspects cervical cancer. The nurse reviews the clients history for risk factors for
this disease. Which history finding is a risk factor for cervical cancer?
a. probenecid (Benemid)
b. cytarabine (ara-C, cytosine arabinoside [Cytosar-U])
c. thioguanine (6-thioguanine, 6-TG)
d. leucovorin (citrovorum factor or folinic acid [Wellcovorin])
11. The nurse is interviewing a male client about his past medical history. Which
preexisting condition may lead the nurse to suspect that a client has colorectal
cancer?
a. Duodenal ulcers
b. Hemorrhoids
c. Weight gain
d. Polyps
Answer D. Colorectal polyps are common with colon cancer. Duodenal ulcers and
hemorrhoids arent preexisting conditions of colorectal cancer. Weight loss not
gain is an indication of colorectal cancer.
12. Nurse Amy is speaking to a group of women about early detection of breast
cancer. The average age of the women in the group is 47. Following the American
Cancer Society guidelines, the nurse should recommend that the women:
13. A male client with a nagging cough makes an appointment to see the physician
after reading that this symptom is one of the seven warning signs of cancer. What is
another warning sign of cancer?
a. Persistent nausea
b. Rash
c. Indigestion
d. Chronic ache or pain
.Answer C. Indigestion, or difficulty swallowing, is one of the seven warning signs of
cancer. The other six are a change in bowel or bladder habits, a sore that does not
heal, unusual bleeding or discharge, a thickening or lump in the breast or
elsewhere, an obvious change in a wart or mole, and a nagging cough or
hoarseness. Persistent nausea may signal stomach cancer but isnt one of the seven
major warning signs. Rash and chronic ache or pain seldom indicate cancer.
15. Nurse Lucia is providing breast cancer education at a community facility. The
American Cancer Society recommends that women get mammograms:
16. Which intervention is appropriate for the nurse caring for a male client in severe
pain receiving a continuous I.V. infusion of morphine?
17. A 35 years old client with ovarian cancer is prescribed hydroxyurea (Hydrea), an
antimetabolite drug. Antimetabolites are a diverse group of antineoplastic agents
that interfere with various metabolic actions of the cell. The mechanism of action of
antimetabolites interferes with:
18. The ABCD method offers one way to assess skin lesions for possible skin cancer.
What does the A stand for?
a. Actinic
b. Asymmetry
c. Arcus
d. Assessment
Answer B. When following the ABCD method for assessing skin lesions, the A stands
for "asymmetry," the B for "border irregularity," the C for "color variation," and the
D for "diameter."
19. When caring for a male client diagnosed with a brain tumor of the parietal lobe,
the nurse expects to assess:
20. A female client is undergoing tests for multiple myeloma. Diagnostic study
findings in multiple myeloma include:
calcium is lost from the bone and reabsorbed in the serum. Serum protein
electrophoresis shows elevated globulin spike. The serum creatinine level may also
be increased.
21. A 35 years old client has been receiving chemotherapy to treat cancer. Which
assessment finding suggests that the client has developed stomatitis (inflammation
of the mouth)?
decrease pain in this highly susceptible client. Checking for signs and symptoms of
stomatitis also wouldnt decrease the pain.
23. What should a male client over age 52 do to help ensure early identification of
prostate cancer?
a. Have a digital rectal examination and prostate-specific antigen (PSA) test done
yearly.
b. Have a transrectal ultrasound every 5 years.
c. Perform monthly testicular self-examinations, especially after age 50.
d. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine
levels checked yearly.
Answer A. The incidence of prostate cancer increases after age 50. The digital rectal
examination, which identifies enlargement or irregularity of the prostate, and PSA
test, a tumor marker for prostate cancer, are effective diagnostic measures that
should be done yearly. Testicular self-examinations wont identify changes in the
prostate gland due to its location in the body. A transrectal ultrasound, CBC, and
BUN and creatinine levels are usually done after diagnosis to identify the extent of
the disease and potential metastases
24. A male client complains of sporadic epigastric pain, yellow skin, nausea,
vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician
orders a diagnostic workup, which reveals gallbladder cancer. Which nursing
diagnosis may be appropriate for this client?
a. Anticipatory grieving
b. Impaired swallowing
c. Disturbed body image
d. Chronic low self-esteem
Answer A. Anticipatory grieving is an appropriate nursing diagnosis for this client
because few clients with gallbladder cancer live more than 1 year after diagnosis.
Impaired swallowing isnt associated with gallbladder cancer. Although surgery
typically is done to remove the gallbladder and, possibly, a section of the liver, it
isnt disfiguring and doesnt cause Disturbed body image. Chronic low self-esteem
isnt an appropriate nursing diagnosis at this time because the diagnosis has just
been made.
a. Stand as far away from the implant as possible and call for help.
b. Pick up the implant with long-handled forceps and place it in a lead-lined
container.
c. Leave the room and notify the radiation therapy department immediately.
d. Put the implant back in place, using forceps and a shield for self-protection, and
call for help.
Answer B. If a radioactive implant becomes dislodged, the nurse should pick it up
with long-handled forceps and place it in a lead-lined container, then notify the
radiation therapy department immediately. The highest priority is to minimize
radiation exposure for the client and the nurse; therefore, the nurse must not take
any action that delays implant removal. Standing as far from the implant as
possible, leaving the room with the implant still exposed, or attempting to put it
back in place can greatly increase the risk of harm to the client and the nurse from
excessive radiation exposure.
26. Jeovina, with advanced breast cancer is prescribed tamoxifen (Nolvadex). When
teaching the client about this drug, the nurse should emphasize the importance of
reporting which adverse reaction immediately?
a. Vision changes
b. Hearing loss
c. Headache
d. Anorexia
Answer A. The client must report changes in visual acuity immediately because this
adverse effect may be irreversible. Tamoxifen isnt associated with hearing loss.
Although the drug may cause anorexia, headache, and hot flashes, the client need
not report these adverse effects immediately because they dont warrant a change
in therapy.
27. A female client with cancer is being evaluated for possible metastasis. Which of
the following is one of the most common metastasis sites for cancer cells?
a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)
Answer A. The liver is one of the five most common cancer metastasis sites. The
others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract,
and WBCs are occasional metastasis sites.
29. Nurse Brian is developing a plan of care for marrow suppression, the major
dose-limiting adverse reaction to floxuridine (FUDR). How long after drug
administration does bone marrow suppression become noticeable?
a. 24 hours
b. 2 to 4 days
c. 7 to 14 days
d. 21 to 28 days
Answer C. Bone marrow suppression becomes noticeable 7 to 14 days after
floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.
30. The nurse is preparing for a female client for magnetic resonance imaging (MRI)
to confirm or rule out a spinal cord lesion. During the MRI scan, which of the
following would pose a threat to the client?
Stage of shock where the body uses defensive mechanisms to correct the insult or
cause.
o
In this stage of shock, compensatory mechanisms begin to fail and organs begin to
fail.
o
Stage of shock where the body uses defensive mechanisms to correct the insult or
cause.
o
Type of shock resulting from a spinal cord insult leading to massive vasodilation.
Neurogenic Shock
Answer:
Type of shock resulting from a spinal cord insult leading to massive vasodilation.
3. Compensatory Stage
o
Stage of shock where the body uses defensive mechanisms to correct the insult or
cause.
o
Stage of shock where the body uses defensive mechanisms to correct the insult or
cause.
4. Shock
Inflammatory state affecting the whole body, frequently a response of the immune
system to infection.
o
At this stage of shock, the vital organs have failed. Brain damage and cell death
have occurred. Death will occur imminently.
o
Type of shock resulting from dysfunction of the heart- either diastolic or systolic
dysfunction.
o
Type of shock that results from the loss of blood due to trauma or hemorrhage.
Answer:
At this stage of shock, the vital organs have failed. Brain damage and cell death
have occurred. Death will occur imminently.
6. Septic Shock
o
Inflammatory state affecting the whole body, frequently a response of the immune
system to infection.
o
Type of shock resulting from a spinal cord insult leading to massive vasodilation.
o
Type of shock resulting from a spinal cord insult leading to massive vasodilation.
o
Inflammatory state affecting the whole body, frequently a response of the immune
system to infection.
o
Stage of shock where the body uses defensive mechanisms to correct the insult or
cause.
o
Inflammatory state affecting the whole body, frequently a response of the immune
system to infection.
9. Progressive or Decompensatory Stage
Inflammatory state affecting the whole body, frequently a response of the immune
system to infection.
o
Type of shock resulting from dysfunction of the heart- either diastolic or systolic
dysfunction.
o
Type of shock that results from the loss of blood due to trauma or hemorrhage.
o
In this stage of shock, compensatory mechanisms begin to fail and organs begin to
fail.
Answer:
In this stage of shock, compensatory mechanisms begin to fail and organs begin to
fail.
10. Hypovolemic Shock
o
At this stage of shock, the vital organs have failed. Brain damage and cell death
have occurred. Death will occur imminently.
o
Type of shock that results from the loss of blood due to trauma or hemorrhage.
Answer:
Type of shock that results from the loss of blood due to trauma or hemorrhage.
11. Obstructive Shock
o
In this stage of shock, compensatory mechanisms begin to fail and organs begin to
fail.
Stage of shock where the body uses defensive mechanisms to correct the insult or
cause.
Answer:
Type of shock that results from the loss of blood due to trauma or hemorrhage.
o
Type of shock resulting from dysfunction of the heart- either diastolic or systolic
dysfunction.
o
At this stage of shock, the vital organs have failed. Brain damage and cell death
have occurred. Death will occur imminently.
o
Stage of shock where the body uses defensive mechanisms to correct the insult or
cause.
Answer:
Type of shock resulting from dysfunction of the heart- either diastolic or systolic
dysfunction.