Chapter 15
The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient’s risk of lung cancer?
a.Teach the patient about the seven warning signs of cancer.
b.Plan to monitor the patient’s carcinoembryonic antigen (CEA) level.
c.Teach the patient about annual chest x-rays for lung cancer screening.
d.Discuss risks associated with cigarette smoking during each patient encounter.
D.
Teaching about the risks associated with cigarette smoking is recommended at every patient encounter because cigarette smoking is associated with multiple health problems. The other options may detect lung cancer that is already present but do not reduce the risk.
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?
a. Yellow-tinged sclerae
c.Numbness of the extremities
b.Shiny, smooth tongue
d.Gum bleeding and tenderness
C. Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
Which menu choice indicates that the patient understands the nurse’s teaching about recommended dietary choices for iron-deficiency anemia?
a.Omelet and whole wheat toast
b.Strawberry and banana fruit plate
c. Cantaloupe and cottage cheese
d.Cornmeal muffin and orange juice
A. Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia
An assessment finding for a 55-yr-old patient that alerts the nurse to the presence of osteoporosis is
a.bowed legs.
b.a loss of height.
c.the report of frequent falls.
d.an aversion to dairy products.
B. Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.
The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with
a.a brief routine of isometric exercises.
b.a warm bath followed by a short rest.
c.active range-of-motion (ROM) exercises.
d.stretching exercises to relieve joint stiffness.
ANS: B
Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.
A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
a.“Benign tumors do not cause damage to other tissues.”
b.“Benign tumors are likely to recur in the same location.”
c.“Malignant tumors may spread to other tissues or organs.”
d.“Malignant cells reproduce more rapidly than normal cells.”
c.
“Malignant tumors may spread to other tissues or organs.”
The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors do not metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur.
The health care provider’s progress note for a patient states that the complete blood count (CBC) shows a “shift to the left.” Which assessment finding will the nurse expect?
a.Cool extremities
b. Pallor and weakness
C.Elevated temperature
d.Low oxygen saturation
C. The term “shift to the left” indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the
a.Schilling test.
b.bilirubin level.
c.gastric analysis.
d.stool occult blood.
ANS: B
Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.
The nurse will determine more teaching is needed if a patient with discomfort from a bunion says, “I will
a.give away my high-heeled shoes.”
b.take ibuprofen (Motrin) if I need it.”
c.use the bunion pad to cushion the area.”
d.only wear sandals, no closed-toe shoes.”
D. The patient can wear shoes that have a wide forefoot (toe box). The other patient statements indicate the teaching has been effective.
A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take?
a.Draw blood for rheumatoid factor analysis.
b.Teach the patient about injections for the nodules.
c.Assess the nodules for skin breakdown or infection.
d.Discuss the need for surgical removal of the nodules.
ANS: C
Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence
A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem?
a.Add protein powder to foods such as casseroles.
b.Tell the patient to eat foods that are high in nutrition.
c.Avoid giving the patient foods that are strongly disliked.
d.Add spices to enhance the flavor of foods that are served.
C. 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 protein powder does not address the issue of taste. The patient’s poor intake is not caused by a lack of information about nutrition.
A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding?
a.Hematocrit of 35%
b.Hemoglobin of 11.8 g/dL
c.Platelet count of 400,000/µL
d.White blood cell (WBC) count of 2800/µL
D.
Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient’s immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of
a. iron.
b.folic acid.
c.cobalamin (vitamin B12).
d.ascorbic acid (vitamin C).
B. folic acid. Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider?
a.Serous wound drainage
b.Right arm muscle spasms
c.Right arm pain with movement
d.Temperature 101.4° F (38.6° C)
ANS: D
An elevated temperature suggests possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture
A patient with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider?
a. Red, scaly patches are noted on the arms.
b.Crackles are auscultated in the lung bases.
c.Hemoglobin is 11.1g/dL, and hematocrit is 35%.
d.Patient has continued pain after first week of etanercept therapy.
ANS: B
Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms.
The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider?
a.Frequent loose stools
b.Nausea and vomiting
c.Elevated white blood count (WBC)
d.Increased carcinoembryonic antigen (CEA)
D.An increase in CEA indicates that the chemotherapy is not effective for the patient’s cancer and may need to be modified. Gastrointestinal adverse effects are common with chemotherapy. The nurse may need to address these, but they would not necessarily indicate a need for a change in therapy. An elevated WBC may indicate infection but does not reflect the effectiveness of the colorectal cancer therapy.
A patient’s complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?
a.“Have you had a recent weight loss?”
b.“Do you have any history of lung disease?”
c.“Have you noticed any dark or bloody stools?”
d.“What is your dietary intake of meats and protein?”
B. The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?
a.Potential complication: seizures
b.Potential complication: infection
c.Potential complication: neurogenic shock
d.Potential complication: pulmonary edema
B. Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.
In which order will the nurse implement these interprofessional interventions prescribed for a patient admitted with acute osteomyelitis with a temperature of 101.2° F? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Obtain blood cultures from two sites.
b. Administer dose of gentamicin 60 mg IV.
c. Send to radiology for computed tomography (CT) scan of right leg.
d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever.
A B D C
The highest treatment priority for possible osteomyelitis is initiation of antibiotic therapy, but cultures should be obtained before administration of antibiotics. Addressing the discomfort of the fever is the next highest priority. Because the purpose of the CT scan is to determine the extent of the infection, it can be done last.
Which patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce the risk for osteoarthritis (OA)?
a.A 56-yr-old man who has a sedentary office job
b. 38-yr-old man who plays on a summer softball team
c.A 56-yr-old woman who works on an automotive assembly line
d.A 38-yr-old woman who is newly diagnosed with diabetes mellitus
ANS: C
OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA.
A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)?
a.Cook food thoroughly before eating.
b.Choose low fiber, low residue foods.
c.Avoid public transportation such as buses.
d.Use rectal suppositories if needed for constipation.
e.Talk to the oncologist before having any dental work.
A C E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics.
Fill In the Blank: Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider?
Assessment
· BP 110/68
· Pulse 98 beats/min
· Brisk capillary refill
· Multiple ecchymoses on arms
Complete Blood Count
Hgb 10.6 g/dL
· Hct 30%
· WBC 5100/µL
· Platelets 19,500/µL
Patient History
· Occasional aspirin use
· Abdominal pain x 1 week
· Large, dark stool this morning
Platelet Count.
The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent but not as indicative of the need for rapid treatment as the platelet count.
A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?
21
To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.
SATA: Which actions will the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur (select all that apply)?
a.Monitor serum calcium.
b.Teach about the need for strict bed rest.
c. discontinue use of sustained-release opioids.
d.Support the left leg when repositioning the patient.
e.Support family and patient as they discuss the prognosis.
A D E
The nurse will monitor for hypercalcemia caused by bone decalcification. Support of the leg helps reduce the risk for pathologic fractures. Although the patient may be reluctant to exercise, activity is important to maintain function and avoid complications associated with immobility. Adequate pain medication, including sustained-release and rapid-acting opioids, is needed for the severe pain often associated with bone cancer. The prognosis for metastatic bone cancer is poor so the patient and family need to be supported as they deal with the reality of the situation.
During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)?
a. sleep disturbances
b.Multiple tender points
c.Cardiac palpitations and dizziness
d.Multijoint inflammation and swelling
e.Widespread bilateral, burning musculoskeletal pain
A B E
These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia.