Module 4 Flashcards
The nurse is caring for a young adult who is dying after an automobile accident. The family members want to donate the client’s organs and ask the nurse how the decision when death has occurred is made. Which of the following is the basis for the nurses’ response to the family in this situation?
A. The client is flaccid and unresponsive.
B. The client is experiencing respiratory acidosis and is on a ventilator.
C. The client is unconscious with no brain stem activity.
D. Respiratory efforts cease and no apical pulse is audible.
C. The client is unconscious with no brain stem activity.
The nurse is providing hospice care to a client who is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which of the following is the basis for the nurses’ response about these symptoms?
A. They will continue to increase until death finally occurs.
B. They are a normal response before these functions decrease.
C. They indicate a reflex response to the slowing of other body systems.
D. They may be associated with an improvement in the client’s condition.
B. They are a normal response before these functions decrease.
The spouse of a client with terminal lung cancer visits daily and cheerfully talks with the client about vacation plans for the next year. When the nurse asks about any concerns, the spouse says, “I’m busy at work, but otherwise things are fine.” Which of the following nursing diagnoses is appropriate?
A. Ineffective denial related to threat of unpleasant reality
B. Anxiety related to threat to current status
C. Caregiver role strain related to inexperience with caregiving
D. Hopelessness related to chronic stress
A. Ineffective denial related to threat of unpleasant reality
The nurse has been caring for a terminally ill client for the past 10 months. The nurse and the family are present when the client dies and feels saddened and tearful as the family members begin to cry. Which of the following actions should the nurse take at this time?
A. Contact a grief counsellor as soon as possible.
B. Cry along with the client’s family members.
C. Leave the home as quickly as possible to allow the family to grieve privately.
D. Consider whether working in hospice is desirable since client losses are common.
B. Cry along with the client’s family members.
The nurse is caring for a client undergoing external radiation and has developed a dry desquamation of the skin in the treatment area. Which of the following client statements indicates that the nurse’s teaching about management of the skin reaction has been effective?
A. “I can buy some aloe gel to use on the area.”
B. “I will expose the treatment area to a sun lamp daily.”
C. “I can use ice packs to relieve itching in the treatment area.”
D. “I will scrub the area with warm water to remove the scales.”
A. “I can buy some aloe gel to use on the area.”
A client with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which of the following interventions should the nurse implement?
A. Teach about the importance of nutrition during treatment.
B. Have the client eat large meals when nausea is not present.
C. Offer dry crackers and carbonated fluids during chemotherapy.
D. Administer prescribed antiemetics 1 hour before the treatments.
D. Administer prescribed antiemetics 1 hour before the treatments.
The nurse is caring for a client who is a single mother of four school-age children and is hospitalized with metastatic ovarian cancer. The nurse finds the client crying, and she tells the nurse that she does not know what will happen to her children when she dies. Which of the following is the most appropriate response?
A. “Why don’t we talk about the options you have for the care of your children?”
B. “Perhaps the children’s father will take care of them when you aren’t able to.”
C. “For now you need to concentrate on getting well, not worry about your children.”
D. “Many clients with cancer live for a long time, so there is time to plan for your children.”
A. “Why don’t we talk about the options you have for the care of your children?”
The nurse is caring for a client with metastatic renal cell carcinoma who is receiving interleukin-2 (IL-2) as an adjuvant therapy. Which of the following mechanisms of action should the nurse teach the client about this therapy?
A. It enhances immunological response to tumour cells.
B. It stimulates malignant cells in the resting phase to enter mitosis.
C. It prevents the bone marrow depression caused by chemotherapy.
D. It protects normal cells from the harmful effects of chemotherapy.
A. It enhances immunological response to tumour cells.
The home health nurse is caring for a client who has been receiving interferon therapy for treatment of cancer. Which statement by the client may indicate a need for a change in treatment?
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 every 4 hours.”
B. “I rarely have the energy to get out of bed.”
The nurse is caring for a client with cancer who has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which of the following nursing actions is most appropriate?
A. Add strained baby meats to foods such as casseroles.
B. Teach the client about foods that are high in nutrition.
C. Avoid giving the client foods that are strongly disliked.
D. Put extra spice in the foods that are served to the client.
C. Avoid giving the client foods that are strongly disliked.
The nurse is teaching a client who has a new diagnosis of acute leukemia about the complications associated with chemotherapy. The client is restless and is looking away, never making eye contact. After the teaching, the client asks the nurse to repeat all of the information. Based on this assessment, which of the following nursing diagnoses is most likely for this client?
A. Ineffective denial related to ineffective coping strategies (leukemia diagnosis)
B. Acute confusion related to pain (infiltration of leukemia cells into the central nervous system)
C. Anxiety related to threat of death (leukemia diagnosis)
D. Deficient knowledge (of chemotherapy) related to insufficient interest in learning
C. Anxiety related to threat of death (leukemia diagnosis)
The nurse is caring for a client who is receiving chemotherapy for leukemia. Which of the following observations require intervention by the nurse?
A. The client ambulates several times a day in the room.
B. The client’s temperature is 38.2°C (100.8°F).
C. The client cleans with a warm washcloth after having a stool.
D. The client uses soap and shampoo to shower every other day.
B. The client’s temperature is 38.2°C (100.8°F).
The nurse is caring for a client with tumour lysis syndrome (TLS) who is taking allopurinol. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the medication? A. Uric acid level B. Serum potassium C. Serum phosphate D. Blood urea nitrogen
A. Uric acid level
When assessing the need for psychological support after the client has diagnosed with stage I cancer of the colon, which of the following questions 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?”
C. “Can you tell me what has been helpful to you in the past when coping with stressful events?”
The nurse obtains information about a hospitalized client who is receiving chemotherapy for cancer of the colon. Which of the following information about the client is most indicative of a need for a change in therapy? A. Poor oral intake B. Increase in carcinoembryonic antigen C. Frequent loose stools D. Complaints of nausea
B. Increase in carcinoembryonic antigen
. The nurse at the clinic is interviewing an older-adult client who is 160 cm tall and weighs 57 kg. The client has not seen a health care provider for 20 years. She walks 11 km most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in client 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
A. Pap testing
C. Sunscreen use
D. Mammography
E. Colorectal screening
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic today to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate?
The woman is:
A. Excited about her pregnancy but nervous about the labour
B. Exhibiting verbal and nonverbal behaviours that do not match
C. Excited about her pregnancy, but her husband is not and this is upsetting to her
D. Not excited about her pregnancy but believes the nurse will respond to her negatively if she states this
B. Exhibiting verbal and nonverbal behaviours that do not match
In an interview, the nurse may find it necessary to take notes to aid memory later. Which statement regarding note taking is true?
A. Note taking may impede the nurse’s observation of the patient’s nonverbal behaviours.
B. Note taking allows the patient to continue at his or her own pace as the nurse records what is said.
C. Note taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.
D. Note taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
A. Note taking may impede the nurse’s observation of the patient’s nonverbal behaviours.
