<P> client undergoing radiation therapy has a severely depressed white blood ce

<Q>A
<TYPE>single</TYPE>
ll (WBC) count. A priority nursing intervention would include which of the follo
<MC1>Place client in a private room and maintain strict aseptic technique with a
wing?</Q>
ll procedures.</MC1>
<MC2>Encourage
<MC3>Educate
<MC4>Encourage
<F>Rationale:
<CORRECT>1</CORRECT>
client
The
client
frequent
immunosuppressed
totoavoid
visitors
include
shaving
fresh
to client
reduce
with
fruits
aclient's
is razor.</MC3>
atandhigh
vegetables
feelings
risk forofininfection.
the diet.</MC2>
isolation.</MC4>
A priva
te room, maintaining aseptic technique, and limiting visitors will reduce exposu
re and risk (options1 and 4). Fresh fruits and vegetables may harbor bacteria; s
erve cooked foods only (option 2). The client with a decreased platelet count sh
ould beNeed:
Cognitive
Client
Integrated
Content
Strategy:counseled
Area:
Level:
Select
Process:
Safe
Adult
Application
the
toHealth:
Effective
Nursing
avoid using
distracterCarethat
Process:
Oncology
razors
Environment:
Implementation
directly
(optionreflects
Safety
3). andtheInfection
purpose of
Control
the WBC an
d the implications
Reference: LeMone, P.,
for &their
Burke,
lossK.during
(2008).radiation.
<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 397.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse is performing an assessment in a local clinic. Based on the history
provided by the clients, which one of the following requires an immediate refer
ral for screening
<MC1>Client who reports
and evaluation?</Q>
unintended weight loss of 25 pounds over the past 3 mont
<MC2>Client whoCancer
hs</MC1>
<MC3>Client
<MC4>Client
<F>Rationale:
<CORRECT>1</CORRECT>
smokescells
reports
consumes 2history
packages
diet
rapidly
high
ofofdivide
long-term
in cigarettes
fatsand
andsun
grow,
low
aexposure</MC3>
day</MC2>
inthus
fiber</MC4>
consuming most of the n
utrients ingested. Therefore, an unexplained, rapid weight loss may be the first
symptom associated with cancer, and immediate evaluation is required (option 1)
. Education regarding health promotion is needed for cigarette smoking (option 2
), sun Need:
Cognitive
Client
Integrated
Content
Strategy:
exposure
Area:
Level:
Eliminate
Process:
Health
Adult
(option
Analysis
Promotion
Nursing
Health:
distracters
3), Oncology
andandthat
Process:
a Maintenance
high-fat,
Analysis
are risklow-fiber
factors.dietSelect
(option
the distracter
4). tha
t is an abnormal
Reference: LeMone,finding.
P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>multi</TYPE>
<P>
</P> 406-407.</F>
is caring for a client receiving chemotherapy prior to a bone marro
w transplant. The client is placed on neutropenic precautions. Which of the foll
owing interventions
<MC1>Restrict
<MC2>Provide
<MC3>Transfer
<MC4>Limit
<MC5>Ensure
<F>Rationale:
<CORRECT>[1,4,5]</CORRECT>
visitors
mask
fresh
young
to
Neutropenic
negative
worn
fruit
arebyhealthy
children
to appropriate
and
care
pressure
precautions
from
vegetables
givers
adults.</MC4>
visiting.</MC1>
room.</MC3>
for
and
arewith
this
visitors.</MC5>
indicated
client?
each meal.</MC2>
for
Select
clients
all who
thatare
apply.</Q>
immunosu
ppressed with a low WBC. The goal is to protect them from potential sources of i
nfection until the bone marrow is able to produce sufficient WBC. Visitors shoul
d be limited to healthy adults (options 1 and 4). The client should avoid fresh
fruits and vegetables (option 2) to reduce contact with microbes that could be p
athological during an immunosuppressed state. For the same reason, masks should
be worn by caregivers and visitors (option 5). A negative pressure room is unnec
essary Need:
Cognitive
Client
Integrated
Content
Strategy:
(option
Area:
Level:
Select
Process:
Safe,
Adult
3).distracters
Application
Effective
Nursing Oncology
Health: Process:
Care would
that Environment:
Implementation
decreaseSafety
the risk
and ofInfection
client contaminatio
Control
n when the LeMone,
Reference: white blood
P., &cellBurke,
countK.is(2008).
severely<i>Medical-surgical
reduced. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 406-407.</F>
is making a home visit to a client receiving external radiation the
rapy on an outpatient basis. Further teaching is necessary when the nurse observ
es the clientradiation
<MC1>Washing
<MC2>Protecting
<MC3>Applying
<MC4>Inspecting
<F>Rationale:
<CORRECT>3</CORRECT>
doing
lotion
Lotion,
skinwhich
with
to
for
deodorant,
site
irritated
damage</MC4>
ofwith
soft,
theloose
following?</Q>
plain
and
skin</MC3>
powders
clothing</MC2>
water should
and patting
not beskin
applied
dry</MC1>
to the radiat
ion site during the treatment period to avoid further irritation to the skin (op
tion 3).Need:
Cognitive
Client
Integrated
Content
Strategy:Area:
Options
Level:
This
Process:
Physiological
Adult
question
1, Health:
Application
2, and
Nursing
is asking
4Oncology
Adaptation:
Process:
are correct
forAssessment
identification
Reduction
actions.of Risk of thePotential
action that incorrec
t. IdentifyLeMone,
Reference: the distracter
P., & Burke,that K.the(2008).
client <i>Medical-surgical
should not do. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.hospitalized
<Q>A
<TYPE>single</TYPE>
<P>
</P> 397.</F> client with an internal radiation implant calls the nurse to t
he room to report the implant is dislodged and is lying in the bed. The nurse's
actions would
<MC1>Applying
<MC2>Use long-handled
includeand
gloves which
forceps
placing
oftothepick
implant
following?</Q>
up implant
in a biohazard
and placebag</MC1>
it into lead containe
<MC3>Have client
r</MC2>
<MC4>Notify
<F>Rationale:
<CORRECT>2</CORRECT>
infection
Direct
pickhandling
up the implant
control personnel
of the implant
andtoplace
dispose
causes
it into
ofexposure
implant</MC4>
lead container</MC3>
to radiation and no
one should directly touch the implant. Gloves and biohazard bags do not offer p
rotection from radiation (option 1). Long-handled forceps should be used to pick
up the implant (option 2). Lead containers are necessary to prevent exposure to
radiation (option 3). Infection control personnel have no role in the disposal
of the implant, which should be returned to the radiation therapy department aft
er properly
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Radio-active
Process:
being
Safe
Adult
Application
placed
Effective
Nursing
Health:
implants
in Oncology
the pose
Care
Process:
lead
Environment:
container
aImplementation
hazard to Safety
(option
anyone
and4).
inInfection
direct contact.
Control Selec
t the distracter
References: LeMone,
thatP.,minimizes
& Burke,exposure
K. (2008). to <i>Medical-surgical
others. nursing: Critica
l thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educati
on, pp.
<Q>A
<TYPE>single</TYPE>
<P>
</P> client
396-397.</F>
with leukemia is undergoing the "conditioning phase" for a bone marr
ow transplant (BMT). The priority nursing diagnosis for this client is which of
the following?</Q>
<MC1>Fatigue
<MC2>Imbalanced
<MC3>Interrupted
<MC4>Risk
<F>Rationale:
<CORRECT>4</CORRECT>
forrelated
infection</MC4>
During
nutrition:
mucous
to membranes</MC3>
the anemia</MC1>
conditioning
less than body phaserequirements</MC2>
additional chemotherapy and total bo
dy irradiation is given to eradicate the leukemic cells from the bone marrow. Th
e bone marrow is depressed and without transplantation, the client will die from
an infection (option 4). Options 1, 2, and 3 are appropriate diagnoses for clie
nts receiving chemotherapy and radiation, but the risk for infection is the high
est priority
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
Process:
during
Physiological
Adult
critical
Analysis
thisword
Nursing
Health:phase.
Integrity:
Process:
Oncology
in the stem Planning
Physiological
is <i>priority</i>.
AdaptationThis tells you that
more than one option could apply to the client, but that one is more important t
han the others. Although all cells produced by the bone marrow are suppressed, s
elect the distracter
Reference: LeMone, P.,that & Burke,
poses K.
the(2008).
greatest<i>Medical-surgical
immediate risk. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 1124.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse has counseled a male 52-year-old client about early detection and s
creening for prostate cancer. The nurse evaluates that the client has understood
<MC1>"I
instructions
shouldwhen
havehea digital
makes whichrectalstatement?</Q>
examination and prostate-specific antigen (
PSA) testdon't
<MC2>"I
<MC3>"I
<MC4>"I
<F>Rationale:
<CORRECT>1</CORRECT>
should
doneThe
need
yearly."</MC1>
have American
aascreening
prostate-specific
digital Cancer
rectal
unless
Society
examination
I develop
antigen
recommends
(PSA)
symptoms."</MC4>
doneayearly."</MC3>
test
digital
donerectal
yearly."</MC2>
examinatio
n and PSA yearly for males beginning at age 50 (option 1). Options 2 and 3 are o
nly partly
Cognitive
Client
Integrated
Content
Strategy:
Reference:
Need:
Area:
Level:
Select
correct,
Process:
LeMone,
Health
Adult
Analysis
theP.,
and
Promotion
Nursing
Health:
distracter
&option
Burke,
Process:
Oncology
and
4K.
that
isMaintenance
(2008).
incorrect.
Evaluation
provides
<i>Medical-surgical
for multiple layers nursing:
of screening.
Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 401.</F>
who had a mastectomy yesterday refuses to look at the incision. The
nurse can best assist the client to cope with the disturbed body image by doing
which of the
<MC1>Tell
<MC2>Encourage
<MC3>Delay
<MC4>Have
<F>Rationale:
<CORRECT>2</CORRECT>
client
wound
following?</Q>
Denial
client
thatisuntil
care
assist eventually
to awith
express
protective
client
the dressing
everyone
feelings
ismechanism,
prepared
accepts
about
change.</MC4>
toand
loss
theduring
lookofloss
atbody
wound.</MC3>
ofpart.</MC2>
thisa time,
body part.</MC1>
the client
needs a supportive environment. Allowing the client to express feelings will en
able an effective adaptation to this change (option 2). Option 1 is not a therap
eutic communication and places the client's concern on hold. Wound care must be
done in order to prevent complications (option 3), and the client is obviously n
ot psychologically
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
Process:
Psychosocial
Adult
goalApplication
ready
of
Communication
Health:
communication
toIntegrity
participate
OncologyandisDocumentation
toinprovide
self-carean environment
(option 4). where the clien
t can continue to voice her concerns with safety. Select the distracter that all
ows the client to maintain her coping mechanism and gradually adjust to the chan
ged body image.
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.assessing
<Q>In
<TYPE>single</TYPE>
<P>
</P> 1828-1830.</F>
a client receiving chemotherapy, which of the following would re
quire further
<MC1>Dry
<MC2>Large
<MC3>Complaints
<MC4>Hair
<F>Rationale:
<CORRECT>2</CORRECT>
mucous
loss
areas
evaluation?</Q>
Options
onof
membranes</MC1>
ofscalp</MC4>
fatigue</MC3>
ecchymosis
1, 3, andin4 are various
common
sites
sideoneffects
body</MC2>
of chemotherapy. Even
though they do require intervention, ecchymotic areas may be a sign of decreased
Cognitive
Client
Integrated
Content
Strategy:
platelet
Need:
Area:
count,
Level:
Eliminate
Process:
Physiological
Adult
making
Analysis
Nursing
Health:
all theIntegrity:
distracters
risk of that
Process:
Oncology hemorrhage
Assessment
Reduction
are expected
the
of Risk
priority
inPotential
a client
(optionreceiving
2). chem
otherapy. Choose
Reference: LeMone,theP.,distracter
& Burke, K. that(2008).
infers<i>Medical-surgical
the greatest risk. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 392-394.</F>
is evaluating the nutritional status of a client who is receiving c
hemotherapy as treatment for cancer. On assessment, which finding could potentia
lly affectskin</MC2>
<MC1>Pale
<MC2>Pale
<MC3>Ecchymotic
<MC4>Ulcerations
<F>Rationale:
<CORRECT>4</CORRECT>
and
theDamage
moist
client's
areas
of oral
mucous
toonthe
nutritional
forearms</MC3>
mucosa</MC4>
membranes</MC1>
mucous membranes,
intake?</Q>especially oral mucous membranes (
stomatitis), leads to painful ulcerations of the mouth, interfering with the cli
ent's desire to eat (option 4). Pale skin and mucous membranes may be a sign of
anemia (options 1 and 2). Ecchymosis may be indicative of a low platelet count (
option Need:
Cognitive
Client
Integrated
Content
Strategy:
3).
Area:
Level:
Review
Process:
Physiological
Adult
Analysis
common
Nursing
Health: sideIntegrity:
Process:
Oncology
effects of Assessment
Physiological
chemotherapy.Adaptation
Focus on the one that is m
ost likely LeMone,
Reference: to interfere
P., &with Burke,
theK.ability
(2008).to<i>Medical-surgical
chew. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 392-394.</F>
</P>