Chapter 06: Stress and Stress Management
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
- An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate?
| a. | Start an IV line to administer antihypertensive medications. |
| b. | Recheck the blood pressure after the patient has been assessed. |
| c. | Discuss the need for hospital admission to control blood pressure. |
| d. | Teach the patient about the stroke risk associated with uncontrolled hypertension. |
ANS: B
When a patient experiences an acute stressor, the BP increases. The nurse should plan to recheck the BP after the patient has stabilized and received treatment. This will provide a more accurate indication of the patient’s usual blood pressure. Elevated BP that occurs in response to acute stress does not increase the risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.
DIF: Cognitive Level: Apply (application) REF: 80
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer. She is usually well organized and calm, but the nurse who is giving her preoperative instructions observes that the patient is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take?
| a. | Ask the health care provider for a psychiatric referral. |
| b. | Focus teaching on preventing postoperative complications. |
| c. | Try to calm the patient before repeating any information about the surgery. |
| d. | Encourage the patient to combine the hysterectomy with surgery for bladder repair. |
ANS: C
Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. It is also important to try to calm the patient by listening to her concerns and fears. Psychiatric referral will not necessarily be needed for her but that can better be evaluated after surgery. Focusing on postoperative care does not address the need for preoperative instruction such as the procedure, NPO instructions before surgery, date and time of surgery, medications to be taken or discontinued before surgery, and so on. The issue of incontinence is not immediately relevant in the discussion of preoperative teaching for her hysterectomy.
DIF: Cognitive Level: Apply (application) REF: 81
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- An adult patient who is hospitalized after a motorcycle crash tells the nurse, “I didn’t sleep last night because I worried about missing work at my new job and losing my insurance coverage.” Which nursing diagnosis is appropriate to include in the plan of care?
| a. | Anxiety | c. | Ineffective denial |
| b. | Defensive coping | d. | Risk prone health behavior |
ANS: A
The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient data do not support defensive coping, ineffective denial, or risk prone health behavior as problems for this patient.
DIF: Cognitive Level: Apply (application) REF: 78
TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity
- A patient is extremely anxious about having a biopsy on a femoral lymph node. Which relaxation technique would be the best choice for the nurse to facilitate during the procedure?
| a. | Yoga stretching | c. | Relaxation breathing |
| b. | Guided imagery | d. | Mindfulness meditation |
ANS: C
Relaxation breathing is an easy relaxation technique to teach and use. The patient should remain still during the biopsy and not move or stretch any of his extremities. Meditation and guided imagery require more time to practice and learn.
DIF: Cognitive Level: Apply (application) REF: 83
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- A patient who has frequent migraines tells the nurse, “My life feels chaotic and out of my control. I could not manage if anything else happens.” Which response should the nurse make initially?
| a. | “Regular exercise may get your mind off the pain.” |
| b. | “Guided imagery can be helpful in regaining control.” |
| c. | “Tell me more about how your life has been recently.” |
| d. | “Your previous coping resources can be helpful to you now.” |
ANS: C
The nurse’s initial strategy should be further assessment of the stressors in the patient’s life. Exercise, guided imagery, or understanding how to use coping strategies that worked in the past may be of assistance to the patient, but more assessment is needed before the nurse can determine this.
DIF: Cognitive Level: Apply (application) REF: 86
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
- A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse knows that this is a painful procedure and wants to try providing music to help the patient relax. Which action is best for the nurse to take?
| a. | Use music composed by Mozart. |
| b. | Play music that does not have words. |
| c. | Ask the patient about music preferences. |
| d. | Select music that has 60 to 80 beats/minute. |
ANS: C
Although music with 60 to 80 beats/min, music without words, and music composed by Mozart are frequently recommended to reduce stress, each patient responds individually to music and personal preferences are important.
DIF: Cognitive Level: Analyze (analysis) REF: 85
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- The nurse teaches a patient who is experiencing stress at work how to use imagery as a relaxation technique. Which statement by the nurse would be appropriate?
| a. | “Think of a place where you feel peaceful and comfortable.” |
| b. | “Place the stress in your life into an image that you can destroy.” |
| c. | “Repeatedly visualize yourself experiencing the distress in your workplace.” |
| d. | “Bring what you hear and sense in your work environment into your image.” |
ANS: A
Imagery is the use of one’s mind to generate images that have a calming effect on the body. When using imagery for relaxation, the patient should visualize a comfortable and peaceful place. The goal is to offer a relaxing retreat from the actual work environment. Imagery that is not intended for relaxation purposes can target a disease, problem, or stressor.
DIF: Cognitive Level: Apply (application) REF: 84
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- An obese female patient who had enjoyed active outdoor activities is stressed because osteoarthritis in her hips now limits her activity. Which action by the nurse will best assist the patient to cope with this situation?
| a. | Have the patient practice frequent relaxation breathing. |
| b. | Ask the patient what outdoor activities she misses the most. |
| c. | Teach the patient to use imagery for reducing pain and stress. |
| d. | Encourage the patient to consider weight loss to improve symptoms. |
ANS: D
For problems that can be changed or controlled, problem-focused coping strategies, such as encouraging the patient to lose weight, are most helpful. The other strategies also may assist the patient in coping with her problem, but they will not be as helpful as a problem-focused strategy.
DIF: Cognitive Level: Analyze (analysis) REF: 86
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- A hospitalized patient with diabetes tells the nurse, “I don’t understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up. This is so frustrating.” Which response by the nurse is accurate?
| a. | “The liver is not able to metabolize glucose as well during stressful times.” |
| b. | “Your diet at the hospital is the most likely cause of the increased glucose.” |
| c. | “The stress of illness causes release of hormones that increase blood glucose.” |
| d. | “It is probably coincidental that your blood glucose is higher when you are ill.” |
ANS: C
The release of cortisol, epinephrine, and norepinephrine increase blood glucose levels. The increase in blood glucose is not coincidental. The liver does not control blood glucose. A patient with diabetes who is hospitalized will be on an appropriate diet to help control blood glucose.
DIF: Cognitive Level: Apply (application) REF: 79
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- A middle-aged male patient with usually well-controlled hypertension and diabetes visits the clinic. Today he has a blood pressure of 174/94 mm Hg and a blood glucose level of 190 mg/dL. What patient information may indicate that additional intervention by the nurse is needed?
| a. | The patient states that he takes his prescribed antihypertensive medications daily. |
| b. | The patient states that both of his parents have high blood pressure and diabetes. |
| c. | The patient indicates that he does blood glucose monitoring several times each day. |
| d. | The patient reports that he and his wife are disputing custody of their 8-yr-old son. |
ANS: D
The increase in blood pressure and glucose levels possibly suggests that stress caused by his divorce and custody battle may be adversely affecting his health. The nurse should assess this further and develop an appropriate plan to assist the patient in decreasing his stress. Although he has been very compliant with his treatment plan in the past, the nurse should assess whether the stress in his life is interfering with his management of his health problems. The family history will not necessarily explain why he has had changes in his blood pressure and glucose levels.
DIF: Cognitive Level: Apply (application) REF: 79
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A patient who is taking antiretroviral medication to control human immunodeficiency virus (HIV) infection tells the nurse about feeling mildly depressed and anxious. Which additional information about the patient is most important to communicate to the health care provider?
| a. | The patient takes vitamin supplements and St. John’s wort. |
| b. | The patient recently experienced the death of a close friend. |
| c. | The patient’s blood pressure has increased to 152/88 mm Hg. |
| d. | The patient expresses anxiety about whether the drugs are effective. |
ANS: A
St. John’s wort interferes with metabolism of medications that use the cytochrome P450 enzyme system, including many HIV medications. The health care provider will need to check for toxicity caused by the drug interactions. Teaching is needed about drug interactions. The other information will also be reported but does not have immediate serious implications for the patient’s health.
DIF: Cognitive Level: Analyze (analysis) REF: 80
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
- A patient who is hospitalized with a pelvic fracture after a motor vehicle accident just received news that the driver of the car died from multiple injuries. What actions should the nurse take based on knowledge of the physiologic stress reactions that may occur in this patient (select all that apply)?
| a. | Assess for bradycardia. |
| b. | Observe for decreased appetite. |
| c. | Ask about epigastric discomfort. |
| d. | Monitor for decreased respiratory rate. |
| e. | Check for elevated blood glucose levels. |
ANS: B, C, E
The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and increase blood glucose levels. In addition, stress causes an increase in respiratory and heart rates.
DIF: Cognitive Level: Analyze (analysis) REF: 78
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Chapter 07: Sleep and Sleep Disorders
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
- A patient complains of difficulty falling asleep and daytime fatigue for the past 6 weeks. What is the best initial action for the nurse to take in determining whether this patient has chronic insomnia?
| a. | Schedule a polysomnograph (PSG). |
| b. | Teach the patient how to use an actigraph. |
| c. | Ask the patient to keep a 2-week sleep diary. |
| d. | Arrange for the patient to have a sleep study. |
ANS: C
The diagnosis of insomnia is made on the basis of subjective complaints and an evaluation of a 1- to 2-week sleep diary completed by the patient. Actigraphy and PSG studies or sleep studies may be used for determining specific sleep disorders but are not necessary to make an initial insomnia diagnosis.
DIF: Cognitive Level: Apply (application) REF: 91
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
- A patient with chronic insomnia asks the nurse about ways to improve sleep quality. Which response by the nurse is accurate?
| a. | Avoid exercise during the day. |
| b. | Keep the bedroom temperature warm. |
| c. | Read in bed for a few minutes each night. |
| d. | Go to bed at the same time every evening. |
ANS: D
A regular evening schedule is recommended to improve sleep time and quality. Aerobic exercise may improve sleep quality but should occur at least 6 hours before bedtime. Reading in bed is discouraged for patients with insomnia. The bedroom temperature should be slightly cool.
DIF: Cognitive Level: Apply (application) REF: 94
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- Which patient statement indicates a need for further teaching about extended-release zolpidem (Ambien CR)?
| a. | “I should take the medication on an empty stomach.” |
| b. | “I will take the medication 1 to 2 hours before bedtime.” |
| c. | “I should not take this medication unless I can sleep for at least 6 hours.” |
| d. | “I will schedule activities that require mental alertness for later in the day.” |
ANS: B
Benzodiazepine receptor agonists such as zolpidem work quickly and should be taken immediately before bedtime. The other patient statements are correct.
DIF: Cognitive Level: Apply (application) REF: 94
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
- The nurse cares for an unstable patient in the intensive care unit (ICU). Which intervention should the nurse include in the plan of care to improve this patient’s sleep quality?
| a. | Ask all visitors to leave the ICU for the night. |
| b. | Lower the level of lighting from 8:00 PM until 7:00 AM. |
| c. | Avoid the use of opioids for pain relief during the evening. |
| d. | Schedule assessments to allow 4 hours of uninterrupted sleep. |
ANS: B
Lowering the level of light will help mimic normal day/night patterns and maximize the opportunity for sleep. Although frequent assessments and opioid use can disturb sleep patterns, these actions are necessary for the care of unstable patients. For some patients, having a family member or friend at the bedside may decrease anxiety and improve sleep.
DIF: Cognitive Level: Apply (application) REF: 96
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- What teaching should be included in the plan of care for a patient with narcolepsy?
| a. | Driving an automobile may be possible with appropriate treatment of narcolepsy. |
| b. | Changes in sleep hygiene are ineffective in improving sleep quality in narcolepsy. |
| c. | Antidepressant drugs are prescribed to treat the depression caused by the disorder. |
| d. | Stimulant drugs should be used for less than a month because of the risk for abuse. |
ANS: A
The accident rate FOR patients with narcolepsy who are receiving appropriate treatment is similar to the general population. Stimulant medications are used on an ongoing basis for patients with narcolepsy. The purpose of antidepressant drugs in the treatment of narcolepsy is the management of cataplexy, not to treat depression. Changes in sleep hygiene are recommended for patients with narcolepsy to improve sleep quality.
DIF: Cognitive Level: Apply (application) REF: 98
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- Which action should the nurse manager promote as an evidence-based practice to support alertness for night shift nurses?
| a. | Arrange for older staff members to work most night shifts. |
| b. | Provide a sleeping area for staff to use for napping at night. |
| c. | Post reminders about the relationship of sleep and alertness. |
| d. | Schedule nursing staff to rotate day and night shifts monthly. |
ANS: B
Short onsite naps will improve alertness. Rotating shifts causes the most disruption in sleep habits. Reminding staff members about the impact of lack of sleep on alertness will not improve sleep or alertness. It is not feasible to schedule nurses based on their ages.
DIF: Cognitive Level: Apply (application) REF: 100
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
- Which information regarding a patient’s sleep is most important for the nurse to communicate to the health care provider?
| a. | A 21-yr-old student who takes melatonin to assist in sleeping when traveling from the United States to Europe |
| b. | A 64-yr-old nurse who works the night shift reports drinking hot chocolate before going to bed in the morning |
| c. | A 41-yr-old librarian who has a body mass index (BMI) of 42 kg/m2 says that the spouse complains about snoring |
| d. | A 32-yr-old accountant who is experiencing a stressful week uses diphenhydramine (Benadryl) for several nights |
ANS: C
The patient’s BMI and snoring suggest possible sleep apnea, which can cause complications such as cardiac dysrhythmias, hypertension, and right-sided heart failure. Melatonin is safe to use as a therapy for jet lag. Short-term use of diphenhydramine in young adults is not a concern. Hot chocolate contains only 5 mg of caffeine and is unlikely to affect this patient’s sleep quality.
DIF: Cognitive Level: Analyze (analysis) REF: 96
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
- What is the first action the nurse should take in addressing a patient’s concerns about insomnia and daytime fatigue?
| a. | Question the patient about the use of over-the-counter sleep aids. |
| b. | Suggest that the patient decrease intake of caffeinated beverages. |
| c. | Advise the patient to get out of bed if unable to fall asleep in 10 to 20 minutes. |
| d. | Recommend that the patient use any prescribed sleep aids for only 2 to 3 weeks. |
ANS: A
The nurse’s first action should be assessment of the patient for factors that may contribute to poor sleep quality or daytime fatigue such as the use of OTC medications. The other actions may be appropriate, but assessment is needed first to choose appropriate interventions to improve the patient’s sleep.
DIF: Cognitive Level: Analyze (analysis) REF: 95
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
- A patient with sleep apnea who uses a continuous positive airway pressure (CPAP) device is preparing to have inpatient surgery. Which instructions should the nurse provide to the patient?
| a. | Schedule a preoperative sleep study. |
| b. | Take your home device to the hospital. |
| c. | Expect intubation with mechanical ventilation after surgery. |
| d. | Avoid requesting pain medication while you are hospitalized. |
ANS: B
The patient should be told to take the CPAP device to the hospital if an overnight stay is expected. Many patients will be able to use their own CPAP equipment. Patients should be treated for pain and monitored for respiratory depression. Another sleep study is not required before surgery. A person with sleep apnea would not routinely be expected to require postoperative intubation and mechanical ventilation.
DIF: Cognitive Level: Apply (application) REF: 96
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- When caring for patients with sleep disorders, which activity can the nurse appropriately delegate to unlicensed assistive personnel (UAP)?
| a. | Assist a patient to place the CPAP device on correctly at bedtime. |
| b. | Interview a patient about risk factors for obstructive sleep disorders. |
| c. | Discuss the benefits of oral appliances in decreasing obstructive sleep apnea. |
| d. | Help a patient choose a new continuous positive airway pressure (CPAP) mask. |
ANS: A
Because a CPAP mask is consistently worn in the same way and will have been previously fitted by a licensed health professional, a UAP can assist the patient with putting the mask on. The other actions require critical thinking and nursing judgment by the RN.
DIF: Cognitive Level: Apply (application) REF: 100
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
- Which information obtained by the nurse about an older adult who complains of occasional insomnia indicates a need for patient teaching (select all that apply)?
| a. | Drinks a cup of coffee every morning with breakfast |
| b. | Eats a snack every evening 1 hour before going to bed |
| c. | Reads or watches television in bed on most evenings |
| d. | Takes a warm bath just before bedtime every night |
| e. | Uses diphenhydramine as an occasional sleep aid |
ANS: C, E
Reading and watching television in bed may contribute to insomnia. Older adults should avoid the use of medications that have anticholinergic effects, such as diphenhydramine. Having a snack 1 hour before bedtime or coffee early in the day should not affect sleep quality. Rituals such as a warm bath before bedtime can enhance sleep quality.
DIF: Cognitive Level: Apply (application) REF: 95
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Chapter 11: Inflammation and Wound Healing
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
- The nurse assesses a patient’s surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?
| a. | Obtain wound cultures. | c. | Notify the health care provider. |
| b. | Document the assessment. | d. | Assess the wound every 2 hours. |
ANS: B
The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.
DIF: Cognitive Level: Apply (application) REF: 165
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first?
| a. | Obtain cultures of the wound. |
| b. | Begin antibiotic administration. |
| c. | Continue to monitor the wound for drainage. |
| d. | Redress the wound with wet-to-dry dressings. |
ANS: A
The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.
DIF: Cognitive Level: Analyze (analysis) REF: 161
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
- A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?
| a. | Skin flushing | c. | Rising body temperature |
| b. | Muscle cramps | d. | Decreasing blood pressure |
ANS: C
The patient’s complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature.
DIF: Cognitive Level: Apply (application) REF: 164
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is appropriate?
| a. | Apply a cooling blanket. |
| b. | Notify the health care provider. |
| c. | Check the patient’s temperature again in 4 hours. |
| d. | Give acetaminophen (Tylenol) prescribed PRN for pain. |
ANS: C
Mild to moderate temperature elevations (<103° F) do not harm young adult patients and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms, and the patient does not require analgesics if not reporting discomfort. There is no need to notify the patient’s health care provider or to use a cooling blanket for a moderate temperature elevation.
DIF: Cognitive Level: Apply (application) REF: 164
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- A patient’s 4 ´ 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?
| a. | Dry gauze dressing | c. | Hydrocolloid dressing |
| b. | Nonadherent dressing | d. | Transparent film dressing |
ANS: C
The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for clean wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.
DIF: Cognitive Level: Apply (application) REF: 169
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- The nurse notes that a patient’s open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic?
| a. | Eschar | c. | Maceration |
| b. | Slough | d. | Undermining |
ANS: D
Undermining is evident when a cotton-tipped applicator is placed in the wound and there is a narrower “lip” around the wound, which widens as the wound deepens. Eschar is a crusted cover over a wound. Slough and maceration refer to loosening friable tissue.
DIF: Cognitive Level: Understand (comprehension) REF: 166
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient?
| a. | Monitor white blood cell counts. |
| b. | Check the skin for areas of redness. |
| c. | Measure the temperature every 2 hours. |
| d. | Ask about feelings of fatigue or malaise. |
ANS: D
The earliest manifestation of an infection may be “just not feeling well.” Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications.
DIF: Cognitive Level: Analyze (analysis) REF: 164
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- The nurse should plan to use a wet-to-dry dressing for which patient?
| a. | A patient who has a pressure ulcer with pink granulation tissue |
| b. | A patient who has a surgical incision with pink, approximated edges |
| c. | A patient who has a full-thickness burn filled with dry, black material |
| d. | A patient who has a wound with purulent drainage and dry brown areas |
ANS: D
Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.
DIF: Cognitive Level: Apply (application) REF: 170
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
| a. | Stage I | c. | Stage III |
| b. | Stage II | d. | Stage IV |
ANS: C
A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.
DIF: Cognitive Level: Understand (comprehension) REF: 173
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family?
| a. | Change the patient’s bedding frequently. |
| b. | Apply a hydrocolloid dressing over the ulcer. |
| c. | Change the patient’s position every 1 to 2 hours. |
| d. | Record the size and appearance of the ulcer weekly. |
ANS: C
The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching.
DIF: Cognitive Level: Analyze (analysis) REF: 174
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- The nurse will perform which action when doing a wet-to-dry dressing change on a patient’s stage III sacral pressure ulcer?
| a. | Administer prescribed PRN hydrocodone 30 minutes before the change. |
| b. | Pour sterile saline onto the new dry dressings after the wound has been packed. |
| c. | Apply antimicrobial ointment before repacking the wound with moist dressings. |
| d. | Soak the old dressings with sterile saline 30 minutes before the dressing change |
ANS: A
Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound but not soaked after packing. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.
DIF: Cognitive Level: Apply (application) REF: 170
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?
| a. | The new nurse cleans the ulcer with half-strength peroxide. |
| b. | The new nurse uses a hydrocolloid dressing (DuoDerm)on the ulcer. |
| c. | The new nurse irrigates the pressure ulcer with saline using a 30-mL syringe. |
| d. | The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. |
ANS: A
Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new nurse are appropriate.
DIF: Cognitive Level: Apply (application) REF: 175
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
- A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?
| a. | Elevate the ankle above heart level. |
| b. | Apply a warm moist pack to the ankle. |
| c. | Ask the patient to try bearing weight on the ankle. |
| d. | Assess the ankle’s passive range of motion (ROM). |
ANS: A
Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues.
DIF: Cognitive Level: Apply (application) REF: 165
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
| a. | The patient has had the heel ulcers for 6 months. |
| b. | The patient takes oral hypoglycemic agents daily. |
| c. | The patient states that the ulcers are very painful. |
| d. | The patient has several incisions that formed keloids. |
ANS: B
The use of oral hypoglycemics indicates diabetes, which can interfere with wound healing. The persistence of the ulcers over the past 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient’s pain will be implemented, but pain does not directly affect wound healing.
DIF: Cognitive Level: Analyze (analysis) Apply REF: 167
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- After receiving a change-of-shift report, which patient should the nurse assess first?
| a. | The patient who has multiple leg wounds with eschar to be debrided |
| b. | The patient receiving chemotherapy who has a temperature of 102° F |
| c. | The patient who requires analgesics before a scheduled dressing change |
| d. | The newly admitted patient with a stage IV pressure ulcer on the coccyx |
ANS: B
Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient.
DIF: Cognitive Level: Analyze (analysis) REF: 164
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
- The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?
| a. | The patient who reports increased tenderness and swelling around a leg wound |
| b. | The patient who was just admitted after suturing of a full-thickness arm wound |
| c. | The patient who needs teaching about home care for a draining abdominal wound |
| d. | The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer |
ANS: D
LPN/LVN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the registered nurse (RN).
DIF: Cognitive Level: Apply (application) REF: 170
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
- The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
| a. | Blood glucose of 136 mg/dL |
| b. | Oral temperature of 101° F (38.3° C) |
| c. | Separation of the proximal wound edges |
| d. | Patient complaint of increased incisional pain |
ANS: C
Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly.
DIF: Cognitive Level: Analyze (analysis) REF: 167
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
- A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse’s highest priority?
| a. | Maintaining the patient’s blood glucose within a normal range |
| b. | Ensuring that the patient has an adequate dietary protein intake |
| c. | Giving antipyretics to keep the temperature less than 102° F (38.9° C) |
| d. | Redressing the surgical incision with a dry, sterile dressing twice daily |
ANS: A
Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition is also important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing.
DIF: Cognitive Level: Analyze (analysis) REF: 167
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
- Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy?
| a. | Low serum albumin level |
| b. | Serosanguineous drainage |
| c. | Deep red and moist wound bed |
| d. | Cobblestone appearance of wound |
ANS: A
With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing.
DIF: Cognitive Level: Analyze (analysis) REF: 169
OBJ: Special Questions: Prioritization MSC: NCLEX: Physiological Integrity
- After the home health nurse teaches a patient’s family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?
| a. | The family member uses a lift sheet to reposition the patient. |
| b. | The family member uses clean tap water to clean the wound. |
| c. | The family member dries the wound using a hair dryer on a low setting. |
| d. | The family member places contaminated dressings in a plastic grocery bag. |
ANS: C
Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care.
DIF: Cognitive Level: Apply (application) REF: 175
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
SHORT ANSWER
- A patient’s temperature has been 101° F (38.3° C) for several days. The patient’s normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?
ANS:
2140 calories
DIF: Cognitive Level: Apply (application) REF: 164
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
OTHER
- A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient’s plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]).
- Administer IV antibiotics.
- Sponge patient with cool water.
- Perform wet-to-dry dressing change.
- Administer acetaminophen (Tylenol).
ANS:
A, D, B, C
The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.
DIF: Cognitive Level: Analyze (analysis) REF: 164
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
Chapter 15: Cancer
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
- 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.” |
ANS: C
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.
DIF: Cognitive Level: Understand (comprehension) REF: 240
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?
| a. | Nausea | c. | Hematuria |
| b. | Alopecia | d. | Xerostomia |
ANS: C
The adverse effects of intravesical chemotherapy are confined to the bladder. The other adverse effects are associated with systemic chemotherapy.
DIF: Cognitive Level: Apply (application) REF: 252
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
- 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. |
ANS: 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.
DIF: Cognitive Level: Apply (application) REF: 237
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
- The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer?
| a. | Fruit salad | c. | Creamed broccoli |
| b. | Baked chicken | d. | Toasted wheat bread |
ANS: B
Protein is needed for wound healing. To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products should also be avoided.
DIF: Cognitive Level: Apply (application) REF: 254
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?
| a. | Obtain more information about the family history. |
| b. | Schedule a sigmoidoscopy to provide baseline data. |
| c. | Teach the patient about the need for a colonoscopy at age 50. |
| d. | Teach the patient how to do home testing for fecal occult blood. |
ANS: A
The patient may be at increased risk for colon cancer, but the nurse’s first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning.
DIF: Cognitive Level: Analyze (analysis) REF: 241
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance
- A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate?
| a. | “The cancer involves only the cervix.” |
| b. | “The cancer cells look like normal cells.” |
| c. | “Further testing is needed to determine the spread of the cancer.” |
| d. | “It is difficult to determine the original site of the cervical cancer.” |
ANS: A
Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.
DIF: Cognitive Level: Apply (application) REF: 241
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?
| a. | “The biopsy will remove the cancer in my prostate gland.” |
| b. | “The biopsy will determine how much longer I have to live.” |
| c. | “The biopsy will help decide the treatment for my enlarged prostate.” |
| d. | “The biopsy will indicate whether the cancer has spread to other organs.” |
ANS: C
A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. A biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient’s life.
DIF: Cognitive Level: Apply (application) REF: 238
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
- The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?
| a. | “After cancer has not recurred for 5 years, it is considered cured.” |
| b. | “The cancer will be cured if the entire tumor is surgically removed.” |
| c. | “I will need follow-up examinations for many years after treatment before I can be considered cured.” |
| d. | “Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation.” |
ANS: C
The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.
DIF: Cognitive Level: Apply (application) REF: 243
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
- A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?
| a. | Pain will be relieved by cutting sensory nerves in the stomach. |
| b. | Relief of pressure in the stomach will promote better nutrition. |
| c. | Decreasing the tumor size will improve the effects of other therapy. |
| d. | Tumor growth will be controlled by the removal of malignant tissue. |
ANS: C
A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs.
DIF: Cognitive Level: Understand (comprehension) REF: 245
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?
| a. | Test all stools for the presence of blood. |
| b. | Maintain a high-residue, high-fiber diet. |
| c. | Clean the perianal area carefully after every bowel movement. |
| d. | Inspect the mouth and throat daily for the appearance of thrush. |
ANS: C
Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.
DIF: Cognitive Level: Apply (application) REF: 251
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- A patient with Hodgkin’s lymphoma who is undergoing external radiation therapy tells the nurse, “I am so tired I can hardly get out of bed in the morning.” Which intervention should the nurse add to the plan of care?
| a. | Minimize activity until the treatment is completed. |
| b. | Establish time to take a short walk almost every day. |
| c. | Consult with a psychiatrist for treatment of depression. |
| d. | Arrange for delivery of a hospital bed to the patient’s home. |
ANS: B
Walking programs are used to keep the patient active without excessive fatigue. Having a hospital bed does not necessarily address the fatigue. The better option is to stay as active as possible while combating fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility.
DIF: Cognitive Level: Apply (application) REF: 253
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?
| a. | The patient has a history of dental caries. |
| b. | The patient swims several days each week. |
| c. | The patient snacks frequently during the day. |
| d. | The patient showers each day with mild soap. |
ANS: B
The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation.
DIF: Cognitive Level: Apply (application) REF: 255
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?
| a. | “I can use ice packs to relieve itching.” |
| b. | “I will scrub the area with warm water.” |
| c. | “I can buy aloe vera gel to use on my skin.” |
| d. | “I will expose my skin to a sun lamp each day.” |
ANS: C
Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.
DIF: Cognitive Level: Apply (application) REF: 255
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
- A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate?
| a. | Have the patient eat large meals when nausea is not present. |
| b. | Offer dry crackers and carbonated fluids during chemotherapy. |
| c. | Administer prescribed antiemetics 1 hour before the treatments. |
| d. | Give the patient a glass of a citrus fruit beverage during treatments. |
ANS: C
Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach.
DIF: Cognitive Level: Apply (application) REF: 251
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?
| a. | Infuse the medication over a short period of time. |
| b. | Stop the infusion if swelling is observed at the site. |
| c. | Administer the chemotherapy through a small-bore catheter. |
| d. | Hold the medication unless a central venous line is available. |
ANS: B
Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices are preferred.
DIF: Cognitive Level: Analyze (analysis) REF: 246
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient’s self-esteem?
| a. | Encourage the patient to purchase a wig or hat to wear when hair loss begins. |
| b. | Suggest that the patient limit social contacts until regrowth of the hair occurs. |
| c. | Teach the patient to wash hair gently with mild shampoo to minimize hair loss. |
| d. | Inform the patient that hair usually grows back once chemotherapy is complete. |
ANS: A
The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicles and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient’s self-esteem.
DIF: Cognitive Level: Apply (application) REF: 256
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
- A patient who has ovarian cancer is crying and tells the nurse, “My husband rarely visits. He just doesn’t care.” The husband indicates to the nurse that he does not know what to say to his wife. Which nursing diagnosis is appropriate for the nurse to add to the plan of care?
| a. | Compromised family coping related to disruption in lifestyle |
| b. | Impaired home maintenance related to perceived role changes |
| c. | Risk for caregiver role strain related to burdens of caregiving responsibilities |
| d. | Dysfunctional family processes related to effect of illness on family members |
ANS: D
The data indicate that this diagnosis is most appropriate because poor communication among the family members is affecting family processes. No data suggest a change in lifestyle or its role as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities.
DIF: Cognitive Level: Apply (application) REF: 265
TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity
- A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?
| a. | Remove food debris from the teeth and oral mucosa with a stiff toothbrush. |
| b. | Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. |
| c. | Gargle and rinse the mouth several times a day with an antiseptic mouthwash. |
| d. | Rinse the mouth before and after each meal and at bedtime with a saline solution. |
ANS: D
The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended.
DIF: Cognitive Level: Apply (application) REF: 251
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?
| a. | Offer the patient frequent small snacks between meals. |
| b. | Assist the patient to choose favorite foods from the menu. |
| c. | Provide teaching about the importance of nutritional intake. |
| d. | Apply prescribed anesthetic gel to oral lesions before meals. |
ANS: D
Because the etiology of the patient’s poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition but would not be as helpful for this patient.
DIF: Cognitive Level: Analyze (analysis) REF: 254
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?
| a. | “Don’t you have any friends that will raise the children for you?” |
| b. | “Would you like to talk about options for the care of your children?” |
| c. | “For now you need to concentrate on getting well and not worrying about your children.” |
| d. | “Many patients with cancer live for a long time, so there is time to plan for your children.” |
ANS: B
This response expresses the nurse’s willingness to listen and recognizes the patient’s concern. The responses beginning “Many patients with cancer live for a long time” and “For now you need to concentrate on getting well” close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient’s friends will raise the children, more assessment information is needed before making plans.
DIF: Cognitive Level: Apply (application) REF: 265
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
- A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?
| a. | The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). |
| b. | The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. |
| c. | The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. |
| d. | The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief. |
ANS: C
For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics may also be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route, and usually the oral route is preferred.
DIF: Cognitive Level: Apply (application) REF: 264
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
- Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?
| a. | IL-2 enhances the body’s immunologic response to tumor cells. |
| b. | IL-2 prevents bone marrow depression caused by chemotherapy. |
| c. | IL-2 protects normal cells from harmful effects of chemotherapy. |
| d. | IL-2 stimulates malignant cells in the resting phase to enter mitosis. |
ANS: A
IL-2 enhances the ability of the patient’s own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression.
DIF: Cognitive Level: Understand (comprehension) REF: 258
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment?
| a. | “I have frequent muscle aches and pains.” |
| b. | “I rarely have the energy to get out of bed.” |
| c. | “I experience chills after I inject the interferon.” |
| d. | “I take acetaminophen (Tylenol) every 4 hours.” |
ANS: B
Fatigue can be a dose-limiting toxicity for use of immunotherapy. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use acetaminophen every 4 hours.
DIF: Cognitive Level: Apply (application) REF: 258
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient’s teaching plan?
| a. | Donor bone marrow is transplanted through a sternal or hip incision. |
| b. | Hospitalization is required for several weeks after the stem cell transplant. |
| c. | The transplant procedure takes place in a sterile operating room to minimize the risk for infection. |
| d. | Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone. |
ANS: B
The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line so the transplant is not painful, nor is an operating room or incision required.
DIF: Cognitive Level: Understand (comprehension) REF: 261
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
- The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?
| a. | Lime sherbet | c. | Fresh strawberries |
| b. | Blueberry yogurt | d. | Cream cheese bagel |
ANS: B
Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Lime sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein.
DIF: Cognitive Level: Apply (application) REF: 261
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
- 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. |
ANS: 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.
DIF: Cognitive Level: Apply (application) REF: 262
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?
| a. | Risk for ineffective adherence to treatment related to denial of need for chemotherapy |
| b. | Acute confusion related to infiltration of leukemia cells into the central nervous system |
| c. | Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment |
| d. | Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis |
ANS: D
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 etiologic factors.
DIF: Cognitive Level: Apply (application) REF: 265
TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity
- A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?
| a. | The patient ambulates around the room. |
| b. | The patient’s visitors bring in fresh peaches. |
| c. | The patient cleans with a warm washcloth after having a stool. |
| d. | The patient uses soap and shampoo to shower every other day. |
ANS: B
Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. 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 prevent skin breakdown and infection.
DIF: Cognitive Level: Apply (application) REF: 253
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the need for psychologic support, which question by the nurse will provide the most information?
| a. | “How long ago were you diagnosed with this cancer?” |
| b. | “Do you have any concerns about body image changes?” |
| c. | “Can you tell me what has been helpful to you in the past when coping with stressful events?” |
| d. | “Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?” |
ANS: C
Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient’s need for support. The patient’s knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Because surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time.
DIF: Cognitive Level: Apply (application) REF: 265
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
- The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?
| a. | Generalized muscle aches |
| b. | Crackles heard at the lung bases |
| c. | Complaints of nausea and anorexia |
| d. | Oral temperature of 100.6° F (38.1° C) |
ANS: B
Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin-2. The patient may need oxygen and the nurse should rapidly notify the health care provider. The other findings are common side effects of interleukin-2.
DIF: Cognitive Level: Analyze (analysis) REF: 257
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
- 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) |
ANS: 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.
DIF: Cognitive Level: Apply (application) REF: 236
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
- The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?
| a. | Hematocrit 30% |
| b. | Platelets 95,000/µL |
| c. | Hemoglobin 10 g/L |
| d. | White blood cells (WBC) 2700/µL |
ANS: D
The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.
DIF: Cognitive Level: Apply (application) REF: 235
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
- When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene?
| a. | The UAP assists the patient to use dental floss after eating. |
| b. | The UAP adds baking soda to the patient’s saline oral rinses. |
| c. | The UAP puts fluoride toothpaste on the patient’s toothbrush. |
| d. | The UAP has the patient rinse after meals with a saline solution. |
ANS: A
Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient.
DIF: Cognitive Level: Apply (application) REF: 261
OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
- The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?
| a. | The UAP flushes the toilet once after emptying the patient’s bedpan. |
| b. | The UAP stands by the patient’s bed for 30 minutes talking with the patient. |
| c. | The UAP places the patient’s bedding in the laundry container in the hallway. |
| d. | The UAP gives the patient an alcohol-containing mouthwash to use for oral care. |
ANS: B
Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine and feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.
DIF: Cognitive Level: Apply (application) REF: 250
OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
- The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?
| a. | A 35-yr-old patient who has wet desquamation associated with abdominal radiation |
| b. | A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer |
| c. | A 24-yr-old patient who received neck radiation and has blood oozing from the neck |
| d. | A 56-yr-old patient who developed a new pericardial friction rub after chest radiation |
ANS: C
Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening.
DIF: Cognitive Level: Analyze (analysis) REF: 263
OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
- Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?
| a. | Teach the patient to rest the brain by avoiding new activities. |
| b. | Teach that “chemo-brain” is a short-term effect of chemotherapy. |
| c. | Report patient symptoms immediately to the health care provider. |
| d. | Suggest use of a daily planner and encourage adequate rest and sleep. |
ANS: D
Use of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop “chemo-brain” while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short or long term. There is no urgent need to report common chemotherapy side effects to the provider.
DIF: Cognitive Level: Apply (application) REF: 252
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
- The nurse assesses a patient with non-Hodgkin’s lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?
| a. | Shortness of breath |
| b. | Shivering and chills |
| c. | Muscle aches and pains |
| d. | Temperature of 100.2° F (37.9° C) |
ANS: A
Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse, but are not indicative of life-threatening complications.
DIF: Cognitive Level: Analyze (analysis) REF: 258
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
- A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?
| a. | Give the patient the prescribed PRN opioid. |
| b. | Assess for sensation and strength in the legs. |
| c. | Notify the health care provider about the symptoms. |
| d. | Teach the patient how to use relaxation to reduce pain. |
ANS: B
Spinal cord compression, an oncologic emergency, can occur with invasion of tumor into the epidural space. The nurse will need to assess the patient further for symptoms such as decreased leg sensation and strength and then notify the health care provider. Administration of opioids or the use of relaxation may be appropriate but only after the nurse has assessed for possible spinal cord compression.
DIF: Cognitive Level: Analyze (analysis) REF: 264
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
- The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider?
| a. | Hematocrit of 32% |
| b. | Pain with deep inspiration |
| c. | Serum sodium of 126 mEq/L |
| d. | Decreased breath sounds on left side |
ANS: C
The syndrome of inappropriate antidiuretic hormone (and the resulting hyponatremia) is an oncologic metabolic emergency and requires rapid treatment to prevent complications such as seizures and coma. The other findings also require intervention but are common in patients with lung cancer and not immediately life threatening.
DIF: Cognitive Level: Analyze (analysis) REF: 263
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
- An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?
| a. | Patient complains of severe fatigue. |
| b. | Patient voids every hour during the day. |
| c. | Patient takes only 50% of meals and refuses snacks. |
| d. | Patient has crackles up to the midline posterior chest. |
ANS: D
Rapid fluid infusions may cause heart failure, especially in older patients. The other findings are common in patients who have cancer or are receiving chemotherapy.
DIF: Cognitive Level: Analyze (analysis) REF: 266
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
- After change-of-shift report on the oncology unit, which patient should the nurse assess first?
| a. | Patient who has a platelet count of 82,000/µL after chemotherapy |
| b. | Patient who has xerostomia after receiving head and neck radiation |
| c. | Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) |
| d. | Patient who is worried about getting the prescribed long-acting opioid on time |
ANS: C
Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/µL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain.
DIF: Cognitive Level: Analyze (analysis) REF: 253
OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
- The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)?
| a. | Pap testing |
| b. | Tobacco use |
| c. | Sunscreen use |
| d. | Mammography |
| e. | Colorectal screening |
ANS: A, C, D, E
The patient’s age, gender, and history indicate a need for screening and teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use tobacco or excessive alcohol, she is physically active, and her body weight is healthy.
DIF: Cognitive Level: Analyze (analysis) REF: 235
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
- 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. |
ANS: 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.
DIF: Cognitive Level: Apply (application) REF: 253
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrit
