What is the single most important risk factor in cataract development? Show
The nurse instructs a patient with primary open-angle glaucoma about the disorder. Which of the following statements, if made by the nurse, is most appropriate? Aycee U. has been diagnosed with glaucoma. She has no other medical conditions and is not scheduled for eye surgery. Which of the following medications would cause you to question the physician's orders? Mr. B. is an
82-year-old man admitted to the day surgery unit for a cataract extraction. The nurse reviewing discharge instructions with Mr. B. should note that. Which is a priority intervention after a patient receives a corneal transplant? Your are caring for a client who had ear surgery 2 days ago and tells you that she needs to blow her nose. What should you tell her? You are caring for a client who has a significant hearing loss. Which of the following behaviors is most effective in communicating with this client? A patient with anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient’s laboratory findings to include a. normal RBC indices. b. a Hct of 38% c. a hemoglobin of 7.6 g/dL d. an RBC count of 4,500,000/uL. A patient who is receiving methotrexate develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron b. folic acid c. cobalamin (vit B12) d. ascorbic acid (vit c) Which menu choice indicates that the patient understands the nurse’s teaching about best dietary choices for iron-deficiency anemia? a. omelet and whole wheat toast b. cantaloupe and cottage cheese C. strawberry and banana fruit plate d. cornmeal muffin and orange juice During the admission assessment of a patient with hemolytic anemia, the nurse notes jaundice of the sclerae. The nurse will plan to check the laboratory results for a. the schilling test b. the bilirubin level. c. the stool occult blood test. d. the gastric analysis testing A patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion, what is the first action that the nurse should take? a. Draw blood for a new crossmatch. b. send a urine specimen to the laboratory. c. give the PRN diphenhydramine (benadryl) d. administer the PRN acetaminphen (tylenol) A 64-year-old with acute myelogenous leukemia (AML) who has induction therapy prescribed asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. if you do not want to have chemotherapy, there are other options for treatment such as stem cell transplantation. b. the decision about chemotherapy is one that you need to make rather than asking what I would do. c.You don’t need to make a decision about treatment right now since leukemias in adults tend to progress quite slowly.” d.“The side effects of the chemotherapy are difficult, but AML frequently does go into remission with chemotherapy.” A 45-year-old patient with acute myelogenous leukemia (AML) is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT). To assist the patient with treatment decisions, the best approach for the nurse to use is to a.emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT. A patient with non-Hodgkin’s lymphoma develops a platelet count of 18,000/µl during chemotherapy. An appropriate nursing intervention for the patient based on this finding is to a. provide oral hygiene every 2 hours. b. check all stools for occult blood. c. check the temperature every 4 hours. d. encourage fluids to 3000 mL/day. The nurse explains that acute leukemia is caused by Select one: a. excessively rapid mitosis of leukemic cells. b. accumulation of immature blast cells. c. proliferation of neutrophils. d. undifferentiated blast cells entering bone marrow. A 22-year-old with acute myelogenous leukemia who is receiving outpatient chemotherapy develops an absolute neutrophil count of 900/µl. Which action by the nurse in the outpatient clinic is most appropriate? Select one: a. Discuss the need for hospital admission to treat the neutropenia. b. Plan to discontinue the chemotherapy until the neutropenia resolves. c. Teach the patient how to administer filgrastim (Neupogen) injections at home. d. Obtain a high-efficiency particulate air (HEPA) filter for the patient for home use. Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. The nurse teaches the patient that the purpose of therapy with this agent is to Select one: a. enhance the patient’s immunologic response to tumor cells. b. stimulate malignant cells in the resting phase to enter mitosis. c. prevent the bone marrow depression caused by chemotherapy. d. protect normal cells from the harmful effects of chemotherapy. A patient with ovarian cancer is distressed because her husband rarely visits and tells the nurse, “He just doesn’t care.” The husband indicates to the nurse that “I never know what to say to help her.” An appropriate nursing diagnosis is Select one: 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. While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse about the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? Select one: 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.” When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to Select one: 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 small-bore catheter. d. hold the medication unless a central venous line is available. A patient with tumor lysis syndrome (TLS) is taking allopurinol (Zyloprim). Which laboratory value should the nurse monitor to determine the effectiveness of the medication? Select one: a. Uric acid level b. Serum potassium c. Serum phosphate d. Blood urea nitrogen The nurse is providing discharge teaching to a patient after a scleral buckling procedure. Which statement, if made by the patient, indicates that the discharge teaching is effective? Select one: a. “I can expect severe pain after this procedure.” b. “I doubt my other eye will ever be affected.” c. “I should avoid lifting heavy objects and straining.” d. “The procedure will correct my vision immediately.” The nurse is examining a patient’s ear to determine if treatment for acute otitis media has been effective. Which assessment finding indicates resolution of the middle ear infection? Select one: a. Tympanic membrane is blue and bulging with no landmarks. b. Cone of light is not present on the tympanic membrane. c. Tympanic membrane has a thin, transparent layer of epithelium. d. Tympanic membrane is pearly gray, shiny, and translucent. A patient is prescribed gentamicin (Garamycin) for an infection. The nurse should assess for which adverse effect of this medication? Select one: a. Increased intraocular pressure b. Exophthalmos c. Fever d. Hearing loss The triage nurse at an ambulatory clinic receives a call from an individual with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this possible eye injury? Select one: a. “Apply a loose dressing over your eyes.” b. “Rinse your eyes immediately with water.” c. “Keep your eyes open to allow tears to form.” d. “Remove any visible metal fragments.” The nurse instructs a patient prescribed dipivefrin (Propine) eye drops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? Select one: a. “The eye drops could cause a fast heart rate and high blood pressure.” b. “I will apply gentle pressure on the inside corner of my eye after each eye drop.” c. “I may experience eye discomfort and redness from use of these eye drops.” d. “I will need to take the eye drops twice a day for at least 2 to 3 months.” A lobectomy is scheduled for a patient with stage I non–small cell lung cancer. The patient tells the nurse, “I would rather have radiation than surgery.” Which response by the nurse is most appropriate? Select one: a. “Are you afraid that the surgery will be very painful?” b. “Did you have bad experiences with previous surgeries?” c. “Surgery is the treatment of choice for stage I lung cancer.” d. “Tell me what you know about the various treatments available.” A patient with newly diagnosed lung cancer tells the nurse, “I think I am going to die pretty soon.” Which response by the nurse is best? Select one: a. “Would you like to talk to the hospital chaplain about your feelings?” b. “Can you tell me what it is that makes you think you will die so soon?” c. “Are you afraid that the treatment for your cancer will not be effective?” d. “Do you think that taking an antidepressant medication would be helpful?” Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. The nurse explains that the test is used to Select one: a. confirm the diagnosis of colon cancer. b. monitor the tumor status after surgery. c. identify the extent of cancer spread or metastasis d. determine the need for postoperative chemotherapy. After teaching a patient to irrigate a new colostomy, the nurse will determine that the teaching has been effective if the patient Select one: a. hangs the irrigating container about 18 inches above the stoma. b. stops the irrigation and removes the irrigating cone if cramping occurs. c. inserts the irrigation tubing no further than 4 to 6 inches into the stoma. d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water. When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes Select one: a. positioning on the right side. b. bed rest for the first 24 hours. c. frequent use of an incentive spirometer. d. chest tubes to water-seal chest drainage. . the nurse determines that an appropriate nursing diagnosis for a patient with iron deficiency anemia is altered nutrition: less than body requirements. What should the nurse analyze first to determine the success of nursing care? A Hemoglobin- the nurse analyzes the patients hemoglobin because it is objective data reflecting improved nutrition. Iron deficiency anemia results in a deficiency in the number of erythrocytes (RBC’s) because a key component in the synthesis of hemoglobin is iron. the nurse is planning general nursing care for older adult residents in a long-term care facility. To maximize tissue oxygenation by preventing anemia in the residents. What is the nurses priority intervention Assess for nutritional deficits- although dependent on several factors, tissue oxygenation is affected by a patients hemoglobin because hemoglobin carries oxygen. Maintaining a residents Hgb can help enhance tissue oxygenation by maximizing the bloods ability to supply oxygen to the tissues. The nurse can help prevent anemia in an older adult by correcting nutritional deficits. a patient who has chronic kidney disease (CKD) has a Hgb of 7.5 g/dL with normocytic, normochromic erythrocytes (RBC’s). what patient assessment would be a reliable clinical indicator of the severity of the patients anemia?- Heart rate- the patients heart rate is a reliable clinical indicator of this type of anemia. Heart rate is a clinical indicator of overall tissue oxygenation. A patient with CKD has anemia of chronic disease because the kidneys fail to produce sufficient livels of erythropoiten leading to insufficient production of RBC’s. . a male patient who was in a motor vehicle accident 2 days ago has a hematocrit of 26%. What additional study can the nurse check to determine if the patients anemia is due to an acute or chronic problem? reticulocyte count- Reticulocytes are immature RBC’s that are released from the bone marrow in response to an acute need such as acute blood loss. In chronic anemia the reticulocytes are likely to be normal. a patient who has a genotype Hb SS has cellulitis above the let ankle. What is the nurses priority for this patient? Maintain tissue perfusion- Cellulitis is an infection of the skin and subcutaneous tissues. However, for a patient with genotype Hb SS (characteristic of sickle cell disease), an infection is a potential crisis because the infection is likely to trigger sickling of the patients RBC’s. as a result, sickling is likely to cause the formation of microthrimbi witht thepotential of decreasing perfusion to distal tissues (the foot). . an African-american woman is expecting her second child. She has sickle cells trait (Hb AS), and her husband has sickle cell anemia (Hb SS). The first child has Hb AS. What is the risk of sickle cell anemia in the fetus? C 50%- the genotype for sickle cell trait is AS, and the genotype for sickle cell anemia is SS. which of the following hematologic disorder(s) is (are) inherited disorders (select all that apply Thalassemia is caused by an autosomal recessive gene that interferes in the globulin synthesis. Hemochromatosis is caused by a recessive gene that results in iron overload, and hemophilia type A is an inherited coagulopathy from deficient clotting factor VIII. which food or dietary supplement(s) administered orally is (are) likely to eliminate the anemia with which it (they) is (are) associated? Iron and iron deficiency anemia- Proper administration of an enteral iron preparation is the treatment of choice for iron deficiency anemia even though it takes weeks or months to correct the anemia. Administering Zinc to a patient with thalaseemia can enhance iron chelation therapy but does not affect the anemia. Coblamin is usually given IM or intranasally because it requires binding to intrinsic factor to be absorbed in the intestines. In pernicious anemia intrinsic factor is not being made. which of the following hematologic disorder(s) can occur from an autoimmune destruction of a blood cell (select all that apply) the destruction of blood cells can be mediated by an autoimmune mechanism. The destructionof neutrophils leading to neutropenia can be a complication of rheumatoid arthritis and systemic lupus erythematosus. Aplastic anemia and pancytopenia including leukopenia, erythrocytopenia and thrombocytopenia can result from immune-mediated destruction such as chemotherapy or radiation. In immune thrombocytopenic purpura, platelets are destroyed. Disseminated intravascular coagulopathy (DIC), which can be the result of an autoimmune disease, causes throbocytoenia. . a male patient who has immune thrombocytopenia prupura ITP) is oozing blood from a venipuncture site that occurred several hours ago. When checking his lab values, the nurse discovers that his serum platelet count is 27,000/uL. What should the nurse do first? A check for occult blood- a patient who has ITP is at risk for bleeding, especially with a platelet count below 30,000uL. patient with hemophilia A receives clotting factors before surgery to remove a benign submandibular tumor. What whould the nurse do in the postoperative period to prevent bleeding? administer tranexamic acid (Cyklokapron)- the nurse administers a clot-stablilizing medication such as tranexamin acid (Cyklokapron to the patient after surgery to enhance the integrity of the surgical incision because it will inhibit plasminogen activation in the fibrin clot. a patient who delivered a baby 2 days ago has developed complications. She is now pale, tachycardic, and lethargic. She is being cared for in the ICU because she developed disseminated intravascular coagulopathy (DIC) after the delivery. What is the nurses priority? Maintain oxygenation- DIC is a bleeding and abnormal clotting disorder and blood loss associated with DIC is usually severe. This patient has clinical indicators of hypoxemia form significant blood loss so the nurses priority is to maintain oxygenation. the nurse plans care for a patient with acute lymphocytic leukemia (ALL). Which should the nurse implement to enhance the chance of remission?- administer daunorubicin (Cerubidine)- the nurse administers daunorubicin (cerubidine) to destroy leukemic cells because the main goal of care for a patient with leukemia is remission. 1. abnormal progressive condition of the lens characterized by opacity unevenness in curvature of cornea Chronic inflammation of the lash follicles and meibomian glands group of disorders characterized by (1) increased intraocular pressure, (2) optic nerve atrophy, and (3)peripheral visual field loss. inner ear disease including episodic vertigo, tinnitus, hearing loss, and aural fullness hereditary condition in which ossification occurs in stapes A hearing loss associated with aging during the course of an interview to assess vision, a patient complains of dry eyes. What should the nurse implement next?- 1. the nurse should evaluate the patients medication list to identify agents that can contribute to dry eyes so follow-up nursing care can be planned. Dry eyes aggravate wearing contact lenses but contact lenses do not normally cause dry eyes. The nurse should not suggest saline eye drops until the etiology of dry eyes is determined. A male patient is recovering from a motor vehicle accident that left him blind. He is withdrawn and refuses to get our of bed. What is the nurses priority goal for this patient?- 1. verbalize feelings related to visual impairment. The nursed priority is to help the patient express his feelings about his vision loss because he is not coping effectively with his situation. Until the patient expresses how he feels he will be unable to progress in his rehabilitation.
The nurse determine that the goal for a patient with viral keratitis is to preserve visual acuity. Which patient outcome is the nurses priority? 1. adhere to therapeutic plan. Adherence to therapy is priority because failure to treat or interruption in therapy can lead to devastating complications. Viral keratitis is common cause of blindness in the united states. Left untreated the infection can lead to a corneal ulcer. The ulcer can result in corneal scarring that can require a corneal transplant for adequate vision. Because the ophthalmic surgeon cannot predict how well the patient will see after cataract surgery, the nurse plans care to prevent patient injury and falls postoperatively. What is the priority assessment? visual acuity with one untreated eye. The nurse needs to determine the patients level of visual acuity to plan care for the prevention of injury and falls. The nurse will use the assessment data to establish goals and choose specific nursing intervention to meet the patients needs. A patient with poor visual acuity is diagnosed with age related macular degeneration (AMD). Which nursing intervention is the nurses priority? assess impact of the vision on normal functioning. The most important nursing intervention is to assess the patients ability to function with visual impairment. The nurse will use the data to plan nursing care including teaching about enhancement techniques and nutrition and assessing the patients coping strategies The nurse is assessing a male patient who is complaining of visual impairment and takes ipratropium (atrovent) for chronic obstructive pulmonary disease. He has a family history of acute angle glaucoma (AACG). Which visual assessment does not indicate AACG Slow visual field loss- ipratropium (atrovent) is an anticholinergic bronchodilator that shoud be used with caution in patients with angle closure glaucoma because it can increase the intraocular pressure by flattening the anterior chamber angle. The assessment finding of gradual loss of the peripheral visual field eliminates AACG as a cause of the patient vision problems because AACG occurs abruptly. A patient who has a 5 year history of glaucoma has a heart block following a myocardial infarction. Which medication for glaucoma must be discontinued to prevent further heart problems? carteolol (Ocupress). Carteolol (Ocupress) is a beta-adrenergic blocking agent that is contraindicated for use in glaucoma patients who have bradycardia or heart block because it is likely the further worsen the conduction defect in the heart An acoustic neuroma of the left ear is removed from a patient, and the nurse instructs the patient about tumor recurrence. The nurse should instruct the patient to monitor for(select all that apply)? 1. C inability to close eye, D episodes of dizziness, E worsening of hearing. Clinical manifestations of tumor recurrence include facial nerve paralysis that can be manifested by an inability to close the eye, intermittent vertigo, and hearing loss. A patient with septic shock is receiving multiple medications. Which IV medication is most likely to cause a hearing loss? 1. vancomycin(Vancocin). The IV medication that is most likely to cause a hearing loss is vancomycin (vacocin because it is an ototoxic medication for the reason, vacomycin (vancocin) IV administration is monitored closely using serum drug levels to maintain therapeutic drug levels and reduce the risk of ototoxicity. Aspirin (bayer aspirin) can also cause hearing loss but it is not administered IV. Neither dopamine (intropin) nor ampicillin (principen) is likely to cause hearing loss. Characterized by reduction below normal in number of erythrocytes Deficiency of red blood cells, white blood cells, and platelets condition in which malignant neoplastic plasma cells infiltrate bone marrow and destroy bone autosomal recessive genetic disorder of inadequate production of normal hemoglobin. abnormal condition with excessive levels of red blood cells progressive megaloblastic marcocytic anemia resulting from inadequate gastric secretion of intrinsic factor microcytic hypochromic anemia caused by inadequate iron supplies Disseminated intravascular coagulation serious coagulopathy resulting from overstimulation of clotting and anticlotting processes I response to disease or injury autosomal recessive disease characterized by increased intestinal iron absobtion. malignant condition characterized by proliferation of abnormal giant, multinucleated cells, called Reed-Sternberg cells, which are located in lymph nodes. hereditary bleeding disorders caused by defective or deficient clotting factors. group of related heatologic disorders characterized by change in quantity and quality of bone marrow elements. A patient’s laboratory test results indicate increased fibrin split products (FSP). An appropriate nursing action is to monitor the patient for a. fever. b. bleeding. c. faintness. d. thrombotic episodes. b. Rationale: During fibrinolysis by plasmin, the fibrin clot is split into smaller molecules known as fibrin split products (FSPs) or fibrin degradation oducts (FDPs). Increased FSPs impair platelet aggregation, reduce prothrombin, and prevent fibrin stabilization and lead to bleeding. Definition When reviewing the results of an 83-year-old patient’s blood tests, which of the following findings would be of most concern to the nurse? a. Platelets of 150,000/mL b. Serum iron of 50 mcg/dL c. Partial thromboplastin time (PTT) of 60 seconds d. Erythrocyte sedimentation rate (ESR) of 35 mm in 1 hour c. Rationale: In aging, the partial thromboplastin time (PTT) is normally decreased, so an abnormally high PTT of 60 seconds is an indication that bleeding could readily occur. Platelets are unaffected by aging, and 150,000/mL is a normal count. Serum iron levels are decreased and the erythrocyte sedimentation rate (ESR) is significantly increased with aging, as are reflected in these values. A patient with a bone marrow disorder has an overproduction of myeloblasts. The nurse would expect the results of a complete blood cell count (CBC) to include increased (select all that apply) a. basophils. b. monocytes. c. neutrophils. d. eosinophils. e. lymphocytes. a, c, d. Rationale: The myeloblast is a committed hematopoietic cell found in the bone marrow from which granulocytes develop. A disorder in which myeloblasts are overproduced would result in increased basophils, eosinophils, and neutrophils During the nursing assessment of a patient with anemia, the nurse asks the patient about a history of a. stomach surgery. b. recurring infections. c. corticosteroid therapy. d. oral contraceptive use. a. Rationale: The parietal cells of the stomach secrete intrinsic factor, a substance necessary for the absorption of cobalamin (vitamin B12), and if all or part of the stomach is removed, the lack of intrinsic factor can lead to impaired RBC production and pernicious anemia. Recurring infections indicate decreased WBCs and immune response, and corticosteroid therapy may cause a neutrophilia and lymphopenia. Oral contraceptive use is strongly associated with changes in blood coagulation. . Using light pressure with the index and middle fingers, the nurse cannot palpate any of the patient’s superficial lymph nodes. The nurse a. records this finding as normal. b. should reassess the lymph nodes using deeper pressure. c. asks the patient about any history of any radiation therapy. d. notifies the health care provider that x-rays of the nodes will be necessary. a. by light palpation, but they are not normally palpable. It may be normal to find small (≤1.0 cm), mobile, firm, nontender nodes. Deep lymph nodes are detected radiographically. . During physical assessment of a patient with thrombocytopenia, the nurse would expect to find a. sternal tenderness. b. petechiae and purpura. c. jaundiced sclera and skin. d. tender, enlarged lymph nodes b. Rationale: Petechiae are small, flat, red or reddish- brown pinpoint microhemorrhages that occur on the skin when platelet levels are low; when they are numerous, they group, causing reddish bruises known as purpura. Jaundice occurs when anemias are of a hemolytic origin, resulting in accumulation of bile pigments from red blood cells (RBCs). Enlarged, tender lymph nodes are associated with infection, and sternal tenderness is associated with leukemias. A patient with a hematologic disorder has a smooth, shiny red tongue. The nurse would expect the patient’s laboratory results to include a. neutrophils: 45%. b. Hb: 9.6 g/dL (96 g/L). c. white blood cell (WBC) count: 13,500/mL. d. red blood cell (RBC) count: 6.4 × 106/mL. b. Rationale: Any smooth, shiny, reddened tongue is an indication of iron-deficiency anemia or pernicious anemia that would be reflected by a decreased hemoglobin level. The increased WBC count could be indicative of an infection; the decreased neutrophils, of neutropenia; and the increased RBCs, of polycythemia. A patient is being treated with chemotherapeutic agents. The nurse revises the patient’s care plan based on the CBC results of a. WBC: 4000/mL. b. RBC: 3.8 × 106/mL. c. platelets: 50,000/mL. d. hematocrit (Hct): 38%. d. Rationale: Any platelet count < 150,000/mL is considered thrombocytopenia and could place the patient at risk for bleeding, necessitating consideration in nursing care. Chemotherapy may cause bone marrow suppression and a depletion of all blood cells. The other factors are all within normal range. Definition If a patient with blood type O Rh+ is given AB Rh– blood, the nurse would expect a. the patient’s Rh factor to react with the RBCs of the donor blood. b. no adverse reaction because the patient has no antibodies against the donor blood. c. the anti-A and anti-B antibodies in the patient’s blood to hemolyze the donor blood. d. the anti-A and anti-B antibodies in the donor blood to hemolyze the patient’s blood. c. Rationale: A patient with O Rh+ blood has no A or B antigens on the RBC but does have anti-A and anti-B antibodies in the blood and has an Rh antigen. AB Rh− blood has both A and B antigens on the RBC but no Rh antigen and no anti-A or anti-B antibodies. If the AB Rh− blood is given to the patient with O Rh+ blood, the antibodies in the patient’s blood will react with the antigens in the donor blood, causing hemolysis of the donor cells. There will be no Rh reaction because the donor blood has no Rh antigen A patient is undergoing a contrast CT of the spleen. Before this test, it is important for the nurse to ask the patient about a. iodine sensitivity. b. prior blood transfusions. c. phobia of confined spaces. d. internal metal implants or appliances. a. Rationale: A contrast CT involves the use of an iodine-based dye that could cause a reaction if the patient is sensitive to iodine. Metal implants or internal appliances and claustrophobia should be determined before magnetic resonance imaging (MRI). Prior blood transfusions are not a factor in this diagnostic test When teaching a patient about a bone marrow examination, the nurse explains that a. the procedure will be done under general anesthesia because it is so painful. b. the patient will not have any pain after the area at the puncture site is anesthetized. c. the patient will experience a brief, very sharp pain during aspiration of the bone marrow. d. there will be no pain during the procedure, but an ache will be present several days afterward. c. Rationale: The aspiration of bone marrow contents is done with local anesthesia at the site of the puncture, but the aspiration causes a suction pain that is quite painful, but very brief. There generally is no residual pain following the test. A lymph node biopsy is most often performed to diagnose a. leukemias. b. hemorrhagic tendencies. c. the cause of lymphedema. d. neoplastic cells in the lymph nodes. d. Rationale: Lymph node biopsy is usually done to determine whether malignant cells are present in lymph nodes and can be used to diagnose lymphomas as well as metastatic spread from any malignant tumor in the body. Leukemias may infiltrate lymph nodes, but biopsy of the nodes is more commonly used to detect any type of neoplastic cells. A patient with a hemoglobin (Hb) level of 7.8 g/dL (78 g/L) has cardiac palpitations, a heart rate of 102, and an increased reticulocyte count. At this severity of anemia, the nurse would also expect the patient to manifest a. pallor. b. dyspnea. c. a smooth tongue. d. sensitivity to cold. b. Rationale: The patient’s hemoglobin (Hb) level indicates a moderate anemia, and at this severity, additional findings usually include dyspnea and fatigue. Pallor, smooth tongue, and sensitivity to cold usually manifest in severe anemia when the Hb level is below 6 g/dL (60 g/L). Priority Decision: A 76-year-old woman has an Hb of 7.3 g/dL (73 g/L) and is experiencing ataxia and confusion on admission to the hospital. A priority nursing intervention for this patient is to a. provide a darkened, quiet room. b. have the family stay with the patient. c. keep top bedside rails up and call bell in close reach. d. question the patient about possible causes of anemia. c. Rationale: In the older adult, confusion, ataxia, and fatigue are common manifestations of anemia and place the patient at risk for injury. Nursing interventions should include safety precautions to prevent falls and injury when these symptoms are present. The nurse is responsible for the patient, not the patient’s family, and, although a quiet room may promote rest, it is not as important as protection of the patient. . During the physical assessment of the patient with severe anemia, which of the following findings is of the most concern to the nurse? a. Anorexia b. Bone pain c. Hepatomegaly d. Dyspnea at rest c. Rationale: In the older adult, confusion, ataxia, and fatigue are common manifestations of anemia and place the patient at risk for injury. Nursing interventions should include safety precautions to prevent falls and injury when these symptoms are present. The nurse is responsible for the patient, not the patient’s family, and, although a quiet room may promote rest, it is not as important as protection of the patient. A nursing diagnosis that is appropriate for patients with moderate to severe anemia of any etiology is a. impaired skin integrity related to edema and pruritus. b. disturbed body image related to changes in appearance and body function. c. imbalanced nutrition: less than body requirements related to lack of knowledge of adequate nutrition. d. activity intolerance related to decreased hemoglobin and imbalance between oxygen supply and demand d. Rationale: Patients with any type of anemia have decreased Hb and symptoms of hypoxemia, leading to activity intolerance. Impaired skin integrity and body image disturbance may be appropriate for patients with jaundice from hemolytic anemias, and altered nutrition is indicated when iron, folic acid, or vitamin B intake is deficient. When teaching the patient about a new prescription for oral iron supplements, the nurse instructs the patient to a. take the iron preparations with meals. b. increase fluid and dietary fiber intake. c. report the presence of black stools to the health care provider. d. use enteric-coated preparations taken with orange juice. b. Rationale: Constipation is a common side effect of oral iron supplementation, and increased fluids and fiber should be consumed to prevent this effect. Because iron can be bound in the GI tract by food, it should be taken before meals unless gastric side effects of the supplements necessitate its ingestion with food. Black stools are an expected result of oral iron preparations. Taking iron with ascorbic acid or orange juice enhances absorption of the iron, but enteric-coated iron often is ineffective because of unpredictable release of the iron in areas of the GI tract where it can be absorbed. . In teaching the patient with pernicious anemia about the disease, the nurse explains that it results from a lack of a. folic acid. b. intrinsic factor. c. extrinsic factor. d. cobalamin intake. b. Rationale: Pernicious anemia is a type of cobalamin (vitamin B12) deficiency that results when parietal cells in the stomach fail to secrete enough intrinsic factor to absorb ingested cobalamin. Extrinsic factor is cobalamin and may be a factor in some cobalamin deficiencies, but not in pernicious anemia. During the assessment of a patient with cobalamin deficiency, the nurse would expect to find that the patient has a. icteric sclera. b. hepatomegaly. c. paresthesia of the hands and feet. d. intermittent heartburn with acid reflux. c. Rationale: Neurologic manifestations of weakness, paresthesias of the feet and hands, and impaired thought processes are characteristic of cobalamin deficiency and pernicious anemia. Hepatomegaly and jaundice often occur with hemolytic anemia and the patient with cobalamin deficiency often has achlorhydria or decreased stomach acidity and would not experience effects of gastric hyperacidity. The nurse determines that teaching about pernicious anemia has been effective when the patient says, a. “This condition can kill me unless I take injections of the vitamin the rest of my life.” b. “My symptoms can be completely reversed if I take cobalamin (vitamin B12) supplements.” c. “If my anemia does not respond to cobalamin therapy, my only other alternative is a bone marrow transplant.” d. “The least expensive and most convenient treatment of pernicious anemia is to use a diet with foods high in cobalamin.” a. Rationale: Without cobalamin replacement, individuals with pernicious anemia will die in 1 to 3 years, but the disease can be controlled with cobalamin supplements for life. Hematologic manifestations can be completely reversed with therapy, but long-standing neuromuscular complications might not be reversed. Because pernicious anemia results from an inability to absorb cobalamin, dietary intake of the vitamin is not a treatment option, nor is a bone marrow transplant. The strict vegetarian is at highest risk for the development of a. thalassemias. b. iron deficiency anemia. c. folic acid deficiency anemia. d. cobalamin deficiency anemia. d. Rationale: Because red meats are the primary dietary source of cobalamin, a strict vegetarian is most at risk for cobalamin-deficiency anemia. Meats are also an important source of iron and folic acid, but whole grains, legumes, and green leafy vegetables also supply these nutrients. Thalassemia is not related to dietary deficiencies. A patient with aplastic anemia has a nursing diagnosis of impaired oral mucous membrane. The etiology of this diagnosis can be related to the effects of a deficiency of (select all that apply) a. platelets. b. RBCs. c. WBCs. d. coagulation factor VIII. a, b, c. Rationale: The anemia of aplastic anemia may cause an inflamed, painful tongue; the thrombocytopenia may contribute to blood-filled bullae in the mouth and gingival bleeding; and the leukopenia may lead to stomatitis and oral ulcers and infections. Coagulation factors are not affected in aplastic anemia. Nursing interventions for the patient with aplastic anemia are directed toward the prevention of the complications of a. fatigue and dyspnea. b. hemorrhage and infection. c. thromboemboli and gangrene. d. cardiac dysrhythmias and heart failure. b. Rationale: Hemorrhage from thrombocytopenia and infection from neutropenia are the greatest risks for the patient with aplastic anemia. The patient will experience fatigue from anemia, but bleeding and infection are the major causes of death in aplastic anemia The anemia of sickle cell disease is caused by a. intravascular hemolysis of sickled RBCs. b. accelerated breakdown of abnormal RBCs. c. autoimmune antibody destruction of RBCs. d. isoimmune antibody-antigen reactions with RBCs. b. Rationale: Because RBCs are abnormal in sickle cell anemia, the mean RBC survival time is 10 to 15 days (rather than the normal 120 days) because of accelerated RBC breakdown by the liver and spleen. Antibody reactions with RBCs may be seen in other types of hemolytic anemias but are not present in sickle cell anemia. . A patient with sickle cell anemia asks the nurse why the sickling crisis does not stop when oxygen therapy is started. The nurse explains that a. sickling occurs in response to decreased blood viscosity, which is not affected by oxygen therapy. b. when RBCs sickle, they occlude small vessels, which causes more local hypoxia and more sickling. c. the primary problem during a sickle cell crisis is destruction of the abnormal cells, resulting in fewer RBCs to carry oxygen. d. oxygen therapy does not alter the shape of the abnormal erythrocytes but only allows for increased oxygen concentration in hemoglobin. b. Rationale: During a sickle cell crisis, the sickling cells clog small capillaries, and the resulting hemostasis promotes a self-perpetuating cycle of local hypoxia, deoxygenation of more erythrocytes, and more sickling. Administration of oxygen may help control further sickling, but additional oxygen does not reach areas of local hypoxia caused by occluded vessels. A nursing intervention that is indicated for the patient during a sickle cell crisis is a. frequent ambulation. b. application of antiembolism hose. c. restriction of sodium and oral fluids. d. administration of large doses of continuous opioid analgesics. d. Rationale: Because pain usually accompanies a sickle cell crisis and may last for 4 to 6 days, pain control is an important part of treatment. Rest is indicated to reduce metabolic needs, and fluids and electrolytes are administered to reduce blood viscosity and maintain renal function. Although thrombosis does occur in capillaries, elastic stockings that primarily affect venous circulation are not indicated. During discharge teaching with a patient with newly diagnosed sickle cell disease, the nurse teaches the patient to a. limit fluid intake. b. avoid hot, humid weather. c. eliminate exercise from the lifestyle. d. seek early medical intervention for upper respiratory infections.
d. Rationale: Because pain usually accompanies a sickle cell crisis and may last for 4 to 6 days, pain control is an important part of treatment. Rest is indicated to reduce metabolic needs, and fluids and electrolytes are administered to reduce blood viscosity and maintain renal function. Although thrombosis does occur in capillaries, elastic stockings that primarily affect venous circulation are not indicated. In providing care for a patient hospitalized with an acute exacerbation of polycythemia vera, the nurse gives priority to which of the following activities? a. Maintaining protective isolation b. Promoting leg exercises and ambulation c. Protecting the patient from injury or falls d. Promoting hydration with a large fluid intake b. Rationale: Thrombus and embolization are the major complications of polycythemia vera because of increased hypervolemia and hyperviscosity. Active or passive leg exercises and ambulation should be implemented to prevent thrombus formation. Hydration therapy is important to decrease blood viscosity, but because the patient already has hypervolemia, a careful balance of intake and output must be maintained and fluids are not injudiciously increased. . A patient has a platelet count of 50,000/mL and is diagnosed with immune thrombocytopenic purpura. The nurse anticipates that initial treatment will include a. splenectomy. b. corticosteroids. c. administration of platelets. d. immunosuppressive therapy. b. Rationale: Corticosteroids are used in initial treatment of idiopathic thrombocytopenic purpura (ITP) because they suppress the phagocytic response of splenic macrophages, decreasing platelet destruction. They also depress autoimmune antibody formation and reduce capillary fragility and bleeding time. All of the other therapies may be used but only in patients who are unresponsive to corticosteroid therapy. Priority Decision: A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which of the following actions is most important for the nurse to implement? a. Taking the temperature every 4 hours to assess for fever b. Maintaining the patient on strict bed rest to prevent injury c. Monitoring the patient for headaches, vertigo, or confusion d. Removing the oral crusting and scabs with a soft brush four times a day c. Rationale: The major complication of thrombocytopenia is hemorrhage, and it may occur in any area of the body. Cerebral hemorrhage may be fatal, and evaluation of mental status for central nervous system (CNS) alterations to identify CNS bleeding is very important. Fever is not a common finding in thrombocytopenia. Protection from injury to prevent bleeding is an important nursing intervention, but strict bed rest is not indicated. Oral care is performed very gently with minimum friction and soft swabs. In reviewing the laboratory results of a patient with hemophilia A (classic), the nurse would expect to find a. an absence of factor IX. b. a decreased platelet count. c. a prolonged bleeding time. d. a prolonged partial thromboplastin time (PTT). d. Rationale: A prolonged PTT occurs when there is a deficiency of clotting factors, such as factor VIII associated with hemophilia A. Factor IX is deficient in hemophilia B, and prolonged bleeding time and decreased platelet counts are associated with platelet deficiencies. A patient with hemophilia comes to the clinic for treatment. The nurse will prepare to administer a. whole blood. b. thromboplastin. c. factor concentrates. d. fresh frozen plasma c. Rationale: Although whole blood and fresh frozen plasma contain the clotting factors that are deficient in hemophilia, specific factor concentrates have been developed that are more pure and safer in preventing infection transmission. Thromboplastin is factor III and is not deficient in patients with hemophilia. . A patient with hemophilia is hospitalized with acute knee pain and swelling. An appropriate nursing intervention for the patient includes a. wrapping the knee with an elastic bandage. b. placing the patient on bed rest and applying ice to the joint. c. administering nonsteroidal antiinflammatory drugs (NSAIDs) as needed for pain. d. gently performing range-of-motion (ROM) exercises to the knee to prevent adhesions b. Rationale: During an acute bleeding episode in a joint, it is important to totally rest the involved joint and slow bleeding with application of ice. Drugs that decrease platelet aggregation, such as aspirin or NSAIDs, should not be used for pain. As soon as bleeding stops, mobilization of the affected area is encouraged with ROM exercises and physical therapy. The most important method for identifying the presence of infection in a neutropenic patient is a. frequent temperature monitoring. b. routine blood and sputum cultures. c. assessing for redness and swelling. d. monitoring white blood cell (WBC) count a. Rationale: An elevated temperature is of most significance in recognizing the presence of an infection in the neutropenic patient because there is no leukocytic response; when the WBC count is depressed, the normal phagocytic mechanisms of infection are impaired, and the classic signs of inflammation may not occur. Cultures are indicated if the temperature is elevated but are not used to monitor for infection. . The major method of preventing infection in the patient with neutropenia is use of a. HEPA filtration rooms. b. prophylactic antibiotics. c. a diet that eliminates fresh fruits and vegetables. d. strict hand washing by all persons in contact with the patient. d. Rationale: Despite its seeming simplicity, hand washing before, during, and after care of the patient with neutropenia is the major method to prevent transmission of harmful pathogens to the patient. HEPA filtration and laminar airflow (LAF) rooms may reduce the number of aerosolized pathogens, but they are expensive and LAF use is controversial. Antibiotics are administered when febrile episodes occur but are not used prophylactically to prevent development of resistance. . Myelodysplastic syndrome (MDS) differs from acute leukemias in that MDS a. has a slower disease progression. b. does not result in bone marrow failure. c. is a clonal disorder of hematopoietic cells. d. affects only the production and function of platelets and WBCs a. Rationale: Although myelodysplastic syndromes, like leukemia, are a group of disorders in which hematopoietic stem cells of the bone marrow undergo clonal change and may cause eventual bone marrow failure, the primary difference from leukemias is that myelodysplastic cells have some degree of maturation, and the disease progression is slower than in acute leukemias. . Lymphadenopathy, splenomegaly, and hepatomegaly are common clinical manifestations of leukemia that are due to a. the development of infection at these sites. b. increased compensatory production of blood cells by these organs. c. infiltration of the organs by increased numbers of WBCs in the blood. d. normal hypertrophy of the organs in an attempt to destroy abnormal cells. c. Rationale: Almost all leukemias cause some degree of hepatosplenomegaly because of infiltration of these organs as well as the bone marrow, lymph nodes, bones, and central nervous system by excessive WBCs in the blood. A patient with acute myelogenous leukemia is considering a hematopoietic stem cell transplant and asks the nurse what is involved. The best response by the nurse is, a. “Your bone marrow is destroyed by radiation, and new bone marrow cells from a matched donor are injected into your bones.” b. “A specimen of your bone marrow may be aspirated and treated to destroy any leukemic cells and then reinfused when your disease becomes worse.” c. “During chemotherapy and total body radiation to destroy all your blood cells, you are given transfusions of red blood cells and platelets to prevent complications.” d. “Leukemic cells and bone marrow stem cells are eliminated with chemotherapy and total body radiation, and new bone marrow cells from a donor are infused.” d. Rationale: Whether the donor bone marrow is from a matched donor or taken from the patient during a remission for later use, hematopoietic stem cell transplant always involves the use of combinations of chemotherapy and total-body radiation to eliminate leukemic cells and the patient’s bone marrow stem cells totally before IV infusion of the donor cells. A severe pancytopenic period follows the transplant, during which the patient must be in protective isolation and during which RBC and platelet transfusions may be given Priority Decision: What are the priority nursing diagnoses for the patient with newly diagnosed chronic lymphocytic leukemia? a. pain and hopelessness b. anxiety and risk for infection c. self-care deficit and ineffective health maintenance d. decisional conflict: treatment options and risk for injury b. Rationale: A patient newly diagnosed with leukemia is most likely to respond with anxiety about the effects and outcome of the disease, and the risk of infection from altered WBCs is always present, even if other blood cells are not yet affected by the disease. Following a splenectomy for the treatment of immune thrombocytopenic purpura (ITP), the nurse would expect the patient’s laboratory test results to reveal a. decreased RBCs. b. decreased WBCs. c. increased platelets. d. increased immunoglobulins. c. Rationale: Splenectomy may be indicated for treatment for ITP, and when the spleen is removed, platelet counts increase significantly in most patients. In any of the disorders in which the spleen removes excessive blood cells, splenectomy will most often increase peripheral RBC, WBC, and platelet counts. . While receiving a unit of packed RBCs, the patient develops chills and a temperature of 102.2° F (39° C). The priority action for the nurse to take is a. notify the health care provider and the blood bank. b. stop the transfusion and removes the IV catheter. c. add a leukocyte reduction filter to the blood administration set. d. recognize this as a mild allergic transfusion reaction and slow the transfusion. b. Rationale: Chills and fever are symptoms of an acute hemolytic or febrile transfusion reaction, and if these develop, the transfusion should be stopped, saline infused through the IV line, the health care provider and blood bank notified immediately, the ID tags rechecked, and vital signs and urine output monitored. The addition of a leukocyte reduction filter may prevent a febrile reaction but is not helpful once the reaction has occurred. Mild and transient allergic reactions indicated by itching and hives might permit restarting of the transfusion after treatment with antihistamines. A patient with thrombocytopenia with active bleeding is to receive two units of platelets. To administer the platelets, the nurse a. checks for ABO compatibility. b. agitates the bag periodically during the transfusion. c. takes vital signs every 15 minutes during the procedure. d. refrigerates the second unit until the first unit has transfused. b. Rationale: Because platelets adhere to the plastic bags, the bag should be gently agitated throughout the transfusion. Platelets do not have A, B, or Rh antibodies, and ABO compatibility is not a consideration. Baseline vital signs should be taken before the transfusion is started, and the nurse should stay with the patient during the first 15 minutes. Platelets are stored at room temperature and should not be refrigerated. Delegation Decision: While administering an infusion of packed RBCs, the RN may delegate which of the following actions to nursing assistive personnel (NAP) (select all that apply)? a. Verify that the IV is patent. b. Obtain the blood products from the blood bank. c. Monitor the blood transfusion rate and adjust as needed. d. Obtain vital signs before and after the first 15 minutes. e. Assist with checking patient identification and blood product identification data with the RN. b, d. Rationale: All other actions are the responsibility of the RN. The LPN may be able to assist with the ID checks (depending on the state and the facility policy). The nurse is presenting a community education program related to cancer prevention. Based on current cancer death rates, the nurse stresses that the most important preventive action for both women and men is a. smoking cessation. b. routine colonoscopies. c. protection from ultraviolet light. d. regular examination of reproductive organs. a. Rationale: Lung cancer is the leading cause of cancer deaths in the United States for both women and men, and smoking cessation is one of the most important cancer-prevention behaviors. Cancers of the reproductive organs are the second leading cause of cancer deaths. The defect in cellular proliferation that occurs in the development of cancer involves a. a rate of cell proliferation that is more rapid than that of normal body cells. b. shortened phases of cell life cycles with occasional skipping of G1 or S phases. c. rearrangement of stem cell RNA that causes abnormal cellular protein synthesis. d. indiscriminate and continuous proliferation of cells with loss of contact inhibition. d. Rationale: Malignant cells proliferate indiscriminately and continuously and also lose the characteristic of contact inhibition, growth on top of and in between other cells. Cancer cells do not usually proliferate at a faster rate than do normal cells, nor can cell cycles be skipped in proliferation; however, malignant proliferation is continuous, unlike normal cells. The presence of carcinoembryonic antigens (CEAs) and a-fetoprotein (AFP) on cell membranes is an indication that cells have a. shifted to more immature metabolic pathways and functions. b. spread from areas of original development to different body tissues. c. become more differentiated as a result of repression of embryonic functions. d. produced abnormal toxins or chemicals that indicate abnormal cellular function. a. Rationale: Cancer cells become more fetal and embryonic (undifferentiated) in appearance and function, and some produce new proteins, such as carcinoembryonic antigen (CEA) and a-fetoprotein (AFP), on cell membranes that reflect a return to more immature functioning. The major difference between benign tumors and malignant tumors is that malignant tumors a. grow at a faster rate. b. are often encapsulated. c. invade and metastasize. d. cause death whereas benign tumors do not. c. Rationale: The major difference between benign and malignant cells is the ability of malignant tumor cells to invade and metastasize. Benign tumors are more often encapsulated and often grow at the same rate as malignant tumors. Benign tumors can cause death by expansion into normal tissues and organs. A small lesion is discovered in a patient’s lung when an x-ray is performed for cervical spine pain. The definitive method of determining if the lesion is malignant is by a. lung scan. b. tissue biopsy. c. CT or PET scan. d. presence of oncofetal antigens in the blood. b. Rationale: Although other tests may be used in diagnosing the presence and extent of cancer, biopsy is the only method by which cells can be determined to be malignant. A patient is admitted to the surgical unit where she is scheduled that day for a bilateral simple mastectomy. The nurse recognizes that this procedure is performed to (select all that apply) a. prevent breast cancer. b. diagnose breast cancer. c. cure or control breast cancer. d. provide palliative care for untreated breast cancer. a., c., d. A simple mastectomy can be done to prevent breast cancer in women with high risk and can be used to control, cure, or provide palliative care to breasts ulcerative with tumors. A mastectomy would not be used for biopsy or otherwise establishing a diagnosis of cancer. Chemotherapy for the treatment of cancer would be most effective in a. a small tumor of the bone. b. a young tumor of the brain. c. a large tumor in a highly vascular area. d. malignant changes in hemopoietic cells. d. Rationale: Positive response of cancer cells to chemotherapy is most likely in tumors that arise from tissue that has a rapid rate of cellular proliferation, have a small number of cancer cells, are young tumors that have a greater percentage of proliferating cells, are not in a protected anatomic site, and have no resistant tumor cells. A state of optimum health and a positive attitude of the patient will also promote chemotherapy success. Definition The nurse uses many precautions during IV administration of vesicant chemotherapeutic agents primarily to prevent a. septicemia. b. extravasation. c. catheter occlusion. d. anaphylactic shock. b. Rationale: One of the major concerns with the IV administration of chemotherapeutic agents is infiltration of drugs into tissue surrounding the infusion site. Many of these drugs are vesicants— drugs that, when infiltrated into the skin, cause severe local breakdown and necrosis. Specific measures to ensure adequate dilution, patency, and early detection of injury are important. When teaching the patient with cancer about chemotherapy, the nurse should a. avoid telling the patient about possible side effects of the drugs to prevent anticipatory anxiety. b. explain that antiemetics, antidiarrheals, and analgesics will be provided as needed to control side effects. c. assure the patient that the side effects from chemotherapy are merely uncomfortable, not life threatening. d. inform the patient that chemotherapy-related alopecia is usually permanent but can be managed with lifelong use of wigs. b. Rationale: Patients should always be taught what to expect during a course of chemotherapy, including side effects and expected outcome. Side effects of chemotherapy are serious and may cause death, but it is important that patients be informed about what measures can be taken to help them cope with the side effects of therapy. Hair loss related to chemotherapy is usually reversible, and short-term use of wigs, scarves, or turbans can be used during and following chemotherapy until the hair grows back. Definition . Normal tissues that may manifest early, acute responses to radiation therapy include a. spleen and liver. b. kidney and nervous tissue. c. bone marrow and gastrointestinal mucosa. d. hollow organs such as the stomach and bladder. c. Rationale: Tissue that is actively proliferating, such as GI mucosa, esophageal and oropharyngeal mucosa, and bone marrow, exhibits early acute responses to radiation therapy. Cartilage, bone, kidney, and nervous tissue that proliferate slowly manifest subacute or late responses. The rationale for treatment of cancer with radiation includes the knowledge that a. radiation damages cellular DNA only in abnormal cells. b. malignant cells respond to the effects of radiation because they more frequently go through mitosis. c. damage to cells will occur only during M and G2 phases of the cell cycle, necessitating a series of treatment. d. normal cells are able to repair radiation-induced damage to DNA and do not have permanent radiation damage. b. Rationale: Radiation ionization breaks chemical bonds in DNA, which renders cells incapable of surviving mitosis. This loss of proliferative capacity yields cellular death at the time of division for both normal cells and cancer cells, but cancer cells are more likely to be dividing because of the loss of control of cellular division. Cells are most radiosensitive in the M and G2 phases, but damage in cells that are not in the M phase will be expressed when division occurs. Normal tissues are usually able to recover from radiation damage but not always, and permanent damage may occur. When a patient is undergoing brachytherapy, it is important for the nurse to recognize that a. the patient will undergo simulation to identify and mark the field of treatment. b. the patient is a source of radiation and personnel must wear film badges during care. c. the goal of this treatment is only palliative and the patient should be aware of the expected outcome. d. computerized dosimetry is used to determine the maximum dose of radiation to the tumor within an acceptable dose to normal tissue. b. Rationale: Brachytherapy is the implantation or insertion of radioactive materials directly into the tumor or in proximity of the tumor and may be curative. The patient is a source of radiation, and in addition to implementing the principles of time, distance, and shielding, film badges should be worn by caregivers to monitor the amount of radiation exposure. Computerized dosimetry and simulation are used in external radiation therapy . To prevent the debilitating cycle of fatigue-depression-fatigue in patients receiving radiation therapy, the nurse encourages the patient to a. implement a walking program. b. ignore the fatigue as much as possible. c. do the most stressful activities when fatigue is tolerable. d. schedule rest periods throughout the day whether fatigue is present or not. a. Rationale: Walking programs are a way for patients to keep active without overtaxing themselves and help combat the depression caused by inactivity. Ignoring the fatigue or overstressing the body can make symptoms worse, and the patient should rest only as necessary. The late effects of chemotherapy and high-dose radiation may include a. third-space syndrome. b. chronic nausea and vomiting. c. persistent myelosuppression. d. secondary resistant malignancies. d. Rationale: Alkylating chemotherapeutic agents and high-dose radiation are most likely to cause secondary resistant malignancies as a late effect of treatment. The other conditions are not known to be later effects of radiation or chemotherapy. Definition . The primary use of biologic therapy in cancer treatment is to a. prevent the fatigue associated with chemotherapy and high-dose radiation. b. enhance or supplement the effects of the host’s immune responses to tumor cells. c. depress the immune system and circulating lymphocytes, as well as increasing a sense of well-being. d. protect normal rapidly reproducing cells of the gastrointestinal system from damage during chemotherapy. b. Rationale: Biologic therapies are normal components of the immune system that have been identified and isolated and are used therapeutically to restore, augment, or modulate host immune system mechanisms to assist in immune activity against cancer cells A side effect common to biologic therapies is a. flulike syndrome. b. bone marrow suppression. c. central nervous system deficits. d. nausea, vomiting, anorexia, and diarrhea. a. Rationale: Virtually all biologic therapies may cause a flulike syndrome that includes headache, fever, chills, myalgias, fatigue, and anorexia. The other side effects may be caused by specific agents, but not by all biologic therapies. While caring for a patient who is at the nadir of chemotherapy, the nurse establishes the highest priority for the nursing diagnosis of a. diarrhea. b. grieving. c. risk for infection. d. imbalanced nutrition: less than body requirements. c. Rationale: The nadir is the point of the lowest blood counts after chemotherapy is started, and it is the time when the patient is most at risk for infection. Because infection is the most common cause of morbidity and death in cancer patients, identification of risk and interventions to protect the patient are of the highest priority. An allogenic hematopoietic stem cell transplant is considered as treatment for a patient with acute myelogenous leukemia. The nurse explains that during this procedure a. there is no risk for graft-versus-host disease because the donated marrow is treated to remove cancer cells. b. bone marrow is obtained from a donor who has an HLA match with the patient. c. the patient’s bone marrow will be removed, treated, stored, and then reinfused after intensive chemotherapy. d. there is no need for posttransplant protective isolation because the stem cells are infused directly into the blood. b. Rationale: An allogenic hematopoietic stem cell (bone marrow) transplant is one in which bone marrow from an HLA-matched donor is infused into a patient who has received high doses of chemotherapy, with or without radiation, to eradicate cancerous cells. In an autologous bone marrow transplant, the patient’s own bone marrow is removed before therapy to destroy the bone marrow. The marrow is treated to remove cancer cells and may be infused right away or frozen and stored for later use. In either case, the new bone marrow will take several weeks to produce new blood cells, and protective isolation is necessary during this time. During initial chemotherapy a patient with leukemia develops hyperkalemia and hyperuricemia. The nurse recognizes these symptoms as an oncologic emergency and anticipates that the priority treatment will be a. establishing ECG monitoring. b. increasing urine output with hydration therapy. c. administering a bisphosphonate such as pamidronate (Aredia). d. restricting fluids and administering hypertonic sodium chloride solution b. Rationale: Hyperkalemia and hyperuricemia are characteristic of tumor lysis syndrome, which is the result of rapid destruction of large numbers of tumor cells. Signs include hyperuricemia that causes acute renal failure, hyperkalemia, hyperphosphatemia, and hypocalcemia. To prevent renal failure and other problems, the primary treatment includes increasing urine production using hydration therapy and decreasing uric acid concentrations using allopurinol (Zyloprim). To determine if an unconscious patient has contact lenses in place, the nurse a. uses a pen light to shine a light obliquely over the eyeball. b. applies drops of fluorescein dye to the eye to stain the lenses yellow. c. touches the cornea lightly with a dry cotton ball to see if the patient reacts. d. tenses the lateral canthus to cause a lens to be ejected if it is present in the eye. a. Rationale: A light shined at an angle over the cornea will illuminate a contact lens, and fluorescein should not have to be used. Cotton balls should not be placed on the cornea, and simply tensing the outer canthus will not dislodge the lens. The choices for correction for a refractive error include (select all that apply) a. LASIK. b. Corneal molding. c. Laser thermal keratoplasty (LTK). d. Photorefractive keratectomy (PRK). e. Surgical implantation of intraocular lens. a, b, c, d, e. Rationale: Refractive errors are the most common visual problem and treatment may be nonsurgical corrections (corrective glasses, contect lenses, corneal molding), surgical therapy (LASIK, PRK), implants (ICRs) and thermal procedures (LTK, CK). A patient tells the nurse on admission to the health care facility that he recently has been classified as legally blind. The nurse recognizes that the patient a. has lost usable vision but has some light perception. b. will need time for grieving and adjusting to living with total blindness. c. will be dependent on others to ensure a safe environment for functioning. d. may be able to perform many tasks and activities with vision enhancement techniques. d. Rationale: A person who is legally blind has some usable vision that will benefit from vision- enhancement techniques. A person with total blindness has no light perception and no usable vision, and one with functional blindness has the loss of usable vision but some light perception. Dependency on others from visual impairment is individual and cannot be assumed. A patient is admitted to the emergency department with a wood splinter imbedded in the right eye. An appropriate intervention by the nurse is to a. irrigate the eye with a large amount of sterile saline. b. carefully remove the splinter with a pair of sterile forceps. c. cover the eye with a dry sterile patch and a protective shield. d. apply light pressure on the closed eye to prevent bleeding or loss of aqueous humor. c. Rationale: Emergency management of foreign bodies in the eye includes covering and shielding the eye, with no attempt to treat the injury, until an ophthalmologist can evaluate the injury. Irrigations are performed as emergency management in chemical exposure. Pressure should never be applied because it might further injure the eye. The nurse teaches all patients with conjunctival infections to use a. artificial tears to moisten and soothe the eyes. b. dark glasses to prevent discomfort of photophobia. c. warm moist compresses to the eyes to promote drainage and healing. d. frequent and thorough hand washing to avoid spreading the infection. d. Rationale: All infections of the conjunctiva or cornea are transmittable, and frequent, thorough hand washing is essential to prevent spread from one eye to the other or to other persons. Artificial tears are not normally used in external eye infection. Photophobia is not experienced by all patients with eye infections, and cold compresses are indicated for some infections. A patient with early cataracts tells the nurse that he is afraid cataract surgery may cause permanent visual damage. The nurse informs the patient that a. progression of the cataracts can be prevented by avoidance of UV light and good dietary management. b.cataractsurgeryisverysafeandwiththeimplantationofanintraocularlens,theneedforglasseswillbeeliminated. c. the cataracts will only worsen with time and should be removed as early as possible to prevent blindness. d. vision-enhancement techniques may improve vision until surgery becomes an acceptable option to maintain desired activities d. Rationale: Although cataracts do become worse with time, surgical extraction is considered an elective procedure and is usually performed when the patient decides that he or she wants or needs to see better for his or her lifestyle. There are no known measures to prevent cataract development or progression. Surgical extraction is safe, but the patient will still need glasses for near vision and for any residual refractive error of the implanted lens. A 60-year-old patient is being prepared for outpatient cataract surgery. When obtaining admission data from the patient, the nurse would expect to find that the patient has a history of a. a painless, sudden, severe loss of vision. b. blurred vision, colored halos around lights, and eye pain. c. a gradual loss of vision with abnormal color perception and glare. d. light flashes, floaters, and a “cobweb” in the field of vision with loss of central or peripheral vision. c. Rationale: The lens opacity of cataracts causes a decrease in vision, abnormal color perception, and glare. Blurred vision, halos around lights, and eye pain are characteristic of glaucoma; light flashes, floaters, and “cobwebs” or “hairnets” in the field of vision followed by a painless, sudden loss of vision are characteristic of detached retina. A patient with bilateral cataracts is scheduled for an extracapsular cataract extraction with an intraocular lens implantation of one eye. Preoperatively, the nurse should a. assess the visual acuity in the unoperated eye to plan the need for postoperative assistance. b. inform the patient that the operative eye will need to be patched for 3 to 4 days postoperatively. c. assure the patient that vision in the operative eye will be improved to near-normal on the first postoperative day. d. teach the patient routine coughing and deep-breathing techniques to use postoperatively to prevent respiratory complications. a. Rationale: Assessment of the visual acuity in the patient’s unoperated eye enables the nurse to determine how visually compromised the patient may be while the operative eye is patched and healing and to plan for assistance until vision improves. The patch on the operative eye is usually removed within 24 hours, and, although vision in the eye may be good, it is not unusual for visual acuity to be reduced immediately after surgery. Activities that are thought to increase intraocular pressure, such as bending, coughing, and Valsalva’s maneuver, are restricted postoperatively. . Following a pneumatic retinopexy, the nurse plans postoperative care of the patient based on the knowledge that a. specific positioning and activity restrictions are likely to be required for several days. b. the patient is frequently hospitalized for 7 to 10 days on bed rest until healing is complete. c. patients experience little or no pain, and development of pain indicates hemorrhage or infection. d. reattachment of the retina commonly fails and patients can be expected to grieve for loss of vision. a. Rationale: Postoperatively the patient must position the head so that the bubble is in contact with the retinal break and may have to maintain this position for up to 16 hours a day for 5 days. The patient may go home within a few hours of surgery or may remain in the hospital for several days. No matter the type of repair, reattachment is successful in 90% of retinal detachments. Postoperative pain is expected and is treated with analgesics. In caring for the patient with age-related macular degeneration (AMD), it is important for the nurse to a. teach the patient how to use topical eyedrops for treatment of AMD. b. emphasize the use of vision enhancement techniques to improve what vision is present. c. encourage the patient to undergo laser treatment to slow the deposit of extracellular debris. d. explain that nothing can be done to save the patient’s vision because there is no treatment for AMD. b. Rationale: The patient with age-related macular degeneration (AMD) can benefit from low-vision aids despite increasing loss of vision, and it is important to promote a positive outlook by not giving patients the impression that “nothing can be done” for them. Laser treatment may help a few patients with choroidal neovascularization, and photodynamic therapy is indicated for a small percentage of patients with wet AMD, but there is no treatment for the increasing deposit of extracellular debris in the retina. . A patient with wet AMD is treated with photodynamic therapy. After the procedure the nurse instructs the patient to a. maintain the head in an upright position for 24 hours. b. avoid blowing the nose or causing jerking movements of the head. c. completely cover all the skin to avoid a thermal burn from sunlight. d. expect to experience blind spots where the laser has caused retinal damage. c. Rationale: Verteporfin, the dye used with photodynamic therapy to destroy abnormal blood vessels, is a photosensitizing drug that can be activated by exposure to sunlight or other high- intensity light. Patients must cover all their skin to avoid thermal burns when exposed to sunlight. Blind spots occur with laser photocoagulation used for dry AMD. Head movements and position are not of concern following this procedure. . Visual impairment occurring with glaucoma results from a. ischemic pressure on the retina and optic nerve. b. clouding of aqueous humor in the anterior chamber. c. deposition of drusen and degeneration of the macula. d. loss of accommodation from paralysis of the ciliary body. a. Rationale: In glaucoma, increased intraocular pressure ultimately damages the optic nerve and retina. Deposition of drusen and degeneration of the macula are characteristic of age-related macular degeneration, and aqueous humor clouding and ciliary body paralysis are not specifically related to eye disorders. . An important health promotion nursing intervention that is relevant to glaucoma is a. teaching individuals at risk for glaucoma about early signs and symptoms of the disease. b. preparing patients with glaucoma for lifestyle changes necessary to adapt to eventual blindness. c. promoting regular measurements of intraocular pressure for early detection and treatment of glaucoma. d. informing patients that glaucoma is curable if eye medications are administered before visual impairment has occurred. c. Rationale: Because glaucoma develops slowly and without symptoms, it is important that intraocular pressure be evaluated every 2 to 4 years in persons between the ages of 40 and 64 and every 1 to 2 years in those over 65 years old. More frequent measurement of intraocular pressure should be done in a patient with a family history of glaucoma, the African American patient, and the patient with diabetes or cardiovascular disease. The disease is chronic, but vision impairment is preventable in most cases with treatment. One of the nurse’s roles in preservation of hearing includes a. advising patients to keep the ears clean of wax with cotton-tipped applicators. b. monitoring patients at risk for drug-induced ototoxicity for tinnitus and vertigo. c. promoting the use of ear protection in work and recreational activity with noise levels above 120 dB. d. advocating MMR (measles, mumps, rubella) immunization in susceptible women as soon as pregnancy is confirmed. b. Rationale: Patients receiving ototoxic drugs should be monitored for tinnitus, hearing loss, and vertigo to prevent further damage caused by the drugs. Ears should not be cleaned with anything but a washcloth and finger, and ear protection should be used in any environment with noise levels above 90 dB. Exposure to the rubella virus during the first 16 weeks of pregnancy may cause fetal deafness, and the vaccine should never be given during pregnancy. Nursing management of the patient with external otitis includes a. irrigating the ear canal with body temperature saline several hours after instilling lubricating eardrops. b. inserting an ear wick into the external canal before each application of eardrops to disperse the medication. c. teaching the patient to prevent further infections by instilling antibiotic drops into the ear canal before swimming. d. administering eardrops without touching the dropper to the auricle and positioning the ear upward for 2 minutes afterward. d. Rationale: Antibiotic eardrops for external otitis should be applied without touching the auricle to avoid contaminating the dropper and the solution, and the patient should hold the ear upward for several minutes to allow the drops to run down the canal. An ear wick may be placed in the canal to help deliver the drops, but it remains in the ear throughout the course of treatment. The use of lubricating eardrops followed by irrigation is performed for impacted cerumen. “Swimmer’s ear” is best prevented by avoiding swimming in contaminated waters; prophylactic antibiotics are not used. Definition Which complication would the nurse monitor for in a patient who has a platelet count below 100000?By definition, thrombocytopenia is a platelet count below 100,000/mm 3. Signs and symptoms include nasal or gingival bleeding; bloody urine, sputum, or stool; petechiae; blood blisters; scleral hemorrhage; purpura; and ecchymosis. A platelet count below 50,000/mm 3 increases the risk of hemorrhage with minor trauma.
Which laboratory value would be monitored in a patient with thrombocytopenia?A complete blood count (CBC) measures the levels of red blood cells, white blood cells, and platelets in your blood. For this test, a small amount of blood is drawn from a blood vessel, usually in your arm. If you have thrombocytopenia, the results of this test will show that your platelet count is low.
Which assessment findings indicate that a patient may be experiencing thrombotic thrombocytopenia purpura?Complete blood count (CBC) findings in patients with thrombotic thrombocytopenic purpura (TTP) are usually as follows: Total white blood cell count is normal or slightly elevated. Hemoglobin concentration is moderately depressed at 8-9 g/dL. Platelet count generally ranges from 20,000-50,000/μL.
Which laboratory test would provide information about the number of megakaryocytes in patient with thrombocytopenia?Bone marrow aspiration reveals the number and appearance of megakaryocytes and is the definitive test for many disorders that cause bone marrow failure.
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Which instructions would the nurse include when discharging a patient with thrombocytopenia
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