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51 Cards in this Set
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LUNG CANCER A client asks, “What is a bronchoscopy?” An appropriate response by the nurse is, “A) bronchoscopy is when…a needle is inserted between two ribs and a piece of the tube is aspirated.” B)a set of x-rays are taken that provide a three-dimensional picture of your lungs.” C)magnetic fields and radio waves are used to obtain sectional pictures of your lungs that outline the tumor.” D) a flexible tube is inserted through your mouth and into your lungs to see the tumor and obtain a biopsy.” |
D. a flexible tube is inserted through your mouth and into your lungs to see the tumor and obtain a biopsy.”Rationale:A bronchoscopy is a diagnostic that is performed by inserting a flexible tube is inserted through your mouth and into your lungs to see the tumor and obtain a biopsy. Inserting a needle between two ribs and aspirating describes a needle biopsy, taking x-rays to provide a three-dimensional picture describes a CT scan and using magnetic fields and radio fields describes using an MRI
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LUNG CANCER The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation?A) The client uses Vicks VapoRub every night before bed. B)The client has had an appendectomy.C) The client takes a multiple vitamin pill every day.D) The client has been coughing up blood in the mornings. |
D. The client has been coughing up blood in the mornings.Rationale:Coughing up blood is not normal and is cause for investigation. It could indicate lung cancer.
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LUNG CANCER Which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer? A) The support available to assist the client at home.B) The distance the client lives from the hospital.C) The client’s ability to do home blood pressure monitoring. D) The clients knowledge of the causes of lung cancer. |
A. The support available to assist the client at home.Rationale:Because clients are discharged as soon as possible from the hospital, it is essential to evaluate the support they have to assist them with self-care at home. The distance the client lives from the hospital is not a critical factor in discharge planning. There are no data indicating that home blood pressure monitoring is needed. Knowledge of the causes of lung cancer, although important, is not the most essential area to evaluate given the client’s postoperative status.
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LUNG CANCER The client diagnosed with lung cancer has been told the cancer has metastasized to the brain. Which intervention should the nurse implement?A) Discuss implementing an advanced directive.B) Explain the use of chemotherapy for brain involvement.C) Teach the client to discontinue driving. D) Have the significant other make decisions for the client. |
A. Discuss implementing an advanced directive.Rationale:This situation indicates a terminal process, and the client should make decisions for the end of life.
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LUNG CANCER The nurse writes a problem of “impaired gas exchange” for a client diagnosed with cancer of the lung. Which interventions should be included in the plan of care? Select all that apply.A) Apply O2 via nasal cannula.B) Have the dietician plan for six small meals per day. C)Place the client in respiratory isolation.D) Assess vital signs for fever.E) Listen to lung sounds every shift and on a PRN (as needed) basis. |
A. Apply O2 via nasal cannula.B. Have the dietician plan for six small meals per day.D. Assess vital signs for fever.E. Listen to lung sounds every shift and on a PRN (as needed) basis.Rationale:Respiratory distress is a common finding in clients diagnosed with lung cancer. The administration of O2 will help the client to use the lung capacity that is available to get O2 to the tissues. Clients with lung cancer frequently become fatigued trying to eat larger meals. Cancer is not communicable, so the client does not need to be in isolation. Clients with cancer of the lung are at risk for developing infection from lowered resistance as a result of treatments. Monitoring for the presence of fever is important. Assessment of the lungs should be completed on a routine and PRN basis.
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LUNG CANCER Which of the following would be a significant intervention to help prevent lung cancer? A) Encourage cigarette smokers to have yearly chest radiographs.B) Instruct people about techniques for smoking cessation.C) Recommend that people have their houses and apartment checked for asbestos leakage.D)Encourage people to install central air cleaners in their homes.. |
B. Instruct people about techniques for smoking cessation.Rationale:Lung cancer is almost entirely associated with heavy cigarette smoking. The American Cancer Society reports that smoking is responsible for more than 80% of lung cancers in men and women. The prevalence of lung cancer is related to the duration and intensity of the smoking, so nurses can best prevent lung cancer by persuading clients to stop smoking. Chest radiographs aid in detection of lung cancer; they do not prevent it. Exposure to asbestos has been implicated as a risk factor for lung cancer, but cigarette smoking is the major risk factor. There are no data to support the use of home air cleaners in the prevention of lung cancer.
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LUNG CANCER A client who underwent a left lower lobectomy has been out of surgery for 48 hours. She is receiving morphine sulfate via a patient-controlled analgesia (PCA) system. She tells the nurse that she has some pain in her left thorax that worsens when she coughs. The nurse should: A) Let the client rest, so that she is not stimulated to cough. B) Encourage the client to take deep breaths to help control the pain. C) Check that the PCA device is functioning properly, and then reassure the client that the machine is working and will relieve her pain.D) Obtain a more detailed assessment of the client’s pain using a pain scale. |
D. Obtain a more detailed assessment of the client’s pain using a pain scale. Rationale:Systematic pain assessment is necessary for adequate pain management in the postoperative client. Guidelines from a variety of health care agencies and nursing groups recommend that institutions adopt a pain assessment scale to assist in facilitating pain management. Even though the client is receiving morphine sulfate by PCA, assessment is needed if she is experiencing pain. The concern is not to eliminate coughing but to control pain adequately. Coughing is necessary to prevent postoperative atelectasis and pneumonia. Breathing exercises may help control pain in some circumstances; however, most clients with thoracic surgery require parenteral opioid analgesics in the early postoperative period. Although it is necessary that the PCA device be checked periodically to ensure that it is functioning properly, if the machine is functional and the client’s pain is not relieved, fur- ther intervention, beginning with a pain assessment, is indicated.
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LUNG CANCER The client is four hours post lobectomy for cancer of the lung. Which assessment data warrants immediate intervention by the nurse? A) The client has an intake of 1,500 mL IV and an output of 1,000 mL.B) The client has 450 mL of bright red drainage in the chest tube.C) The client is complaining of pain at a 10 on a 1 – 10 scale.D) The client has absent lung sounds of the side of the surgery. |
B. The client has 450 mL of bright red drainage in the chest tube.Rationale:This is about a pint of blood loss and could indicate hemorrhaging. (Test taking hint! Blood is always a priority).
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LUNG CANCER The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach? A) The test will confirm the results of the MRI. B) The client can eat and drink immediately after the test. C) The HCP can do a biopsy of the tumor through the scope.D) There is no discomfort associated with this procedure. |
C. The HCP can do a biopsy of the tumor through the scope.Rationale:The HCP can take biopsies and perform a washing of the lung tissue for a pathological diagnosis during the procedure.
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LUNG CANCER The nurse is discussing cancer statistics with a group from the community. Which information about death rates from lung cancer is accurate?A)Lung cancer is the number-two cause of cancer deaths in both men and women.B) Lung cancer is the number-one cause of cancer deaths in both men and women. C) Lung cancer deaths are not significant in relation to other cancers. D) Lung cancer deaths have continued to increase in the male population. |
B. Lung cancer is the number-one cause of cancer deaths in both men and women. Rationale:Lung cancer is the number-one cause of cancer deaths in the United States.Lung cancers are responsible for almost twice as many deaths among males as any other cancer and more deaths than breast cancer in females. Lung cancers are the most deadly cancers among the United States population. Lung cancer deaths have remained relatively stable among the male population but have continued to steadily increase among females.
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BREAST CANCER 1) The nurse is planning a focused breast/axilla interview and wants to include a general health question. Which of the following questions would fit this criteria?a. Has your mother or sister had breast cancer?b. Have you ever had a mammogram?c. Are you still menstruating?d. Have you had any breast trauma? |
Answerc. Are you still menstruating?Rationale: General health questions for the breast/axilla focused interview include a description of the breasts, changes in the breasts with menstruation, and date of the last menstrual period.
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BREAST CANCER During the breast exam, the nurse asks the client to raise her arms over her head. Why did the nurse change the client's position?A) Skin dimpling is accented in this position.b. The nurse couldn't palpate the axillae correctly.c. The client has small breasts.d. The client has large breasts. |
Answera. Skin dimpling is accented in this position
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BREAST CANCER 3) The client tells the nurse, "At times I have drainage from my right breast." What should the nurse do with this information?a. Write it in the medical record and say nothing to the client.b. Phone for a mammogram for the client immediately.c. Explain that this could be benign or it could mean something else. It needs to be further investigated.d. Nothing. It doesn't mean a thing. |
Answerc. Explain that this could be benign or it could mean something else. It needs to be further investigated.
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BREAST CANCER 4) When teaching a 22-year-old patient about breast self-examination (BSE), the nurse will instruct the patient thata. BSE will reduce the risk of dying from breast cancer.b. performing BSE right after the menstrual period will improve comfort.c. BSE should be done daily while taking a bath or shower.d. annual mammograms should be scheduled in addition to BSE |
Answerb. performing BSE right after the menstrual period will improve comfort.Rationale: Performing BSE at the end of the menstrual period will reduce the breast tenderness associated with the procedure. The evidence is not clear that BSE reduces breast cancer mortality. BSE should be done monthly. Annual mammograms are not routinely scheduled for women under age 40.
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BREAST CANCER 5) While the nurse is obtaining a nursing history from a 52-year-old patient who has found a small lump in her breast, which question is most pertinent?a. "Do you currently smoke cigarettes?“b. "Have you ever had any breast injuries?“c. "Is there any family history of fibrocystic breast changes?“d. "At what age did you start having menstrual periods?" |
AnswerD. "At what age did you start having menstrual periods?"Rationale: Early menarche and late menopause are risk factors for breast cancer because of the prolonged exposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibrocystic breast changes are not associated with increased breast cancer risk.
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BREAST CANCER 6) During examination of a 67-year-old man, the nurse notes bilateral enlargement of the breasts. The nurse's first action should be toa. palpate the breasts for the presence of any discrete lumps.b. explain that this is a temporary condition caused by hormonal changes.c. refer the patient for mammography and biopsy of the breast tissue.d. teach the patient about dietary changes to reduce the breast size. |
Answera. palpate the breasts for the presence of any discrete lumps.Rationale: If discrete, circumscribed lumps are present, the patient should be referred for further testing to determine whether breast cancer is present. Gynecomastia is usually a temporary change, but it can be caused by breast cancer. Mammography and biopsy will not be needed unless lumps are present in the breast tissue. Dietary changes will not affect the condition.
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BREAST CANCER 7) Which of these findings in the breast of a patient who is suspected of having breast cancer would support the diagnosis?a. complaints of dull, achy, painb. palpation of a mobile massc. presence of an inverted nippled. area of discoloration skin |
Answerc. presence of an inverted nippleRationale: Inverted nipple is one of the manifestations of breast cancer. Palpation of a mobile mass is no correct because cancerous lesions are not mobile.
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BREAST CANCER 8) A pregnant client is upset and thinks she has breast disease because she has a thick white discharge coming from her left breast. What can the nurse say or do for this client?Help the client understand that she might not be able to breastfeed her infant. Nothing. This client needs a mammogram as soon as possible. Call the physician. This information is not normal.A thick yellow discharge from the breasts during pregnancy is normal. |
Answerd. thick yellow discharge from the breasts during pregnancy is normal.
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BREAST CANCER 9) A client is diagnosed with breast cancer. The tumor size is up to 5 cm with axillary and neck lymph node involvement. The client is in what stage of breast cancer?a. Stage Ib. Stage IIc. Stage IIId. Stage IV |
Answerb. Stage IIRationale: Stage I – tumor size up to 2 cm. Stage II – tumor size up to 5 cm with axillary and neck lymph node involvement. Stage III – tumor size is more than 5 cm with axillary and neck lymph node involvement. Stage IV – metastasis to distant organs (liver, lungs, bone and brain).
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BREAST CANCER 10)The nurse is teaching a postmenopausal patient with breast cancer about the expected outcomes of her cancer treatment. The nurse evaluates that the teaching has been effective when the patient saysa. "After cancer has not recurred for 5 years, it is considered cured.“b. "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured.“c. "Cancer is considered cured if the entire tumor is surgically removed.“d. "Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation." |
Answerb. “I will need to have follow-up examinations for many years after I have treatment before I can be considered cured.”Rationale: The risk of recurrence varies by the type of cancer; for breast cancer in postmenopausal women, the patient needs at least 20 disease-free years to be considered cured. Some cancers (e.g., leukemia) are cured by nonsurgical therapies such as radiation and chemotherapy.
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GYN 1) The nurse is teaching a 17-year old, sexually active female about the importance of regular Papanicolau (PAP) smear. The nurse should instruct the client that:A) Pap smears are recommended every other year.B) If four consecutive Pap smears are negative, the client should schedule repeat Pap smears every three years.c. The initial Pap smear should be done when at age 21.d. The client should request a colonoscopy. |
Answer: C The American and Canadian cancer societies and American College of Obstetricians and Gynecologists recommend a Pap smear and pelvic examination 3 years after a woman first has vaginal intercourse, but no later than 21 years of age. Annual Pap smears are only recommended for clients at risk. Women 21-30 years should have a Pap test every 2 years. Women older than 30 years, after 3 or more negative Pap smears, may have Pap smears every three years. Colonoscopy is indicated for a client with an abnormal Pap smear.
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GYN 2) The nurse provides instructions to the client who received cryosurgery for a local stage 0 cervical tumor. The nurse tells the client:a) to avoid tub bathsb) to call the physician if a watery discharge occursc) that pain indicates a complication of the procedured) to call the physician if the discharge remains odorous after 1 week |
Answer: A Healing takes about 10 weeks. Showers or sponge baths should be taken during this time; tub baths and sitz baths need to be avoided. Mild pain may occur and continue for several days after this procedure. A clear, watery discharge is expected. For about 14 days, this is followed by discharge that contains debris, which may be odorous. If the discharge continues for more than 8 weeks, an infection is suspected.
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GYN 3) The community nurse is conducting a health promotion program at a local school and is discussing the risk factors associated with cervical cancer. Which of the following, if identified by the client as a risk factor to cervical cancer, indicates a need for further teaching?a) smokingb) multiple sex partnersc) first intercourse after age 20d) annual gynecological examinations |
Answer: C Risk factors for cervical cancer include human papillomavirus (HPV) infection, active and passive cigarette smoking, certain high-risk sexual activities (first intercourse before 17 years of age, multiple sex partners, or male partners with multiple sex partners). Screening via regular gynecological exams and Papanicolaou smear (Pap test) with treatment of precancerous abnormalities decrease the incidence and mortality of cervical cancer.
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GYN 4) When planning care for a client being treated for cervical cancer, it would be a priority for the nurse to include which of the following in the plan of care? a) Instruction on birth control methods b) Vigorous fluid hydration c) Assessment of sexual function d) Daily weights |
Answer C Surgery and radiation therapy for cervical cancer often results in shortening of the vagina, vaginal dryness, and loss of libido due to emotional issues related to sexuality and femininity. Therefore, the client’s feelings about sexuality and the partner’s feelings should be assessed. If a client is not sexually active, instructions should be given in the use of a vaginal dilator and lubricant to prevent adhesion of the vaginal walls. While instruction about birth control methods may be needed for some clients, treatment for cervical cancer may include total abdominal hysterectomy, so that this would not be appropriate for all clients. Encouraging fluids and daily weights are not priorities in cervical cancer care.
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GYN 5) When assessing a patient's needs for psychological support after the patient has been diagnosed with stage I endometrial cancer, which question by the nurse will provide the most information? "Can you tell me what has been helpful to you in the past when coping with stressful events?" "How long ago were you diagnosed with this cancer?" "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?" "How do you feel about having a possibly terminal illness?" |
Answer: A 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. The patient with stage I cancer is not considered to have a terminal illness at this time, and this question is likely to worry the patient unnecessarily.
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GYN 6) While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?A) Call the health care provider B) Reinsert the implant into the vagina C)Pick up the plant with gloved hands and flush it down the toilet D) Pick up the implant with long-handled forceps and place it in a lead container. |
Answer: D In the event that a radiation source becomes dislodged, the nurse would first encourage the client to lie still until the radioactive source has been placed in a safe closed container. The nurse would use long-handled forceps to place the source in the lead container that should be in the client’s room. The nurse should then call the radiation oncologist and then document the event and the actions taken. It is not within the scope of nursing practice to insert a radiation implant.
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GYN 7) During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease? A) Diarrhea B) Hypermenorrhea C) Abnormal bleedingD) Abdominal distention |
Answer: D Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea is associated with uterine cancer.
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GYN 8) The home health care nurse is caring for a client with uterine cancer who is complaining of acute pain. The most appropriate determination of the client’s pain should include which assessment?A. The client’s pain rating B. Nonverbal cues from the clientC. The nurse’s impression of the client’s painD. Pain relief after appropriate nursing intervention |
Answer: A The client’s self-report is a critical component of pain assessment. The nurse should ask the client to describe the pain and listen carefully to the words the client uses to describe the pain. Nonverbal cues are important but not the most appropriate pain assessment measure. The nurse’s impression of the client’s pain is not appropriate in determining the client’s level of pain. Assessing pain relief is also an important measure, but this option is not related to the subject of the question.
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GYN 9) In teaching about cancer prevention to a community group, the nurse stresses promotion of exercise, normal body weight, and low-fat diet becauseA) most people are willing to make these changes to avoid cancer.B) dietary fat and obesity promote growth of many types of cancer.C)people who exercise and eat healthy will make other lifestyle changes.D)obesity and lack of exercise cause cancer in susceptible people. |
Answer: B Obesity and dietary fat promote the growth of malignant cells, and decreasing these risk factors can reduce the chance of cancer development. Many people are not willing to make these changes. Good diet and exercise habits are not a guarantee that other healthy lifestyle changes will then occur. Obesity and lack of exercise do not cause cancer, but they promote the growth of altered cells.
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GYN 10) A hospitalized patient who has received chemotherapy for ovarian cancer develops neutropenia. Which observation by the RN caring for the patient indicates that the nurse should take action?A) The patient's visitors bring in some fresh peaches from home.B) The patient ambulates several times a day in the room.C) The patient uses soap and shampoo to shower every other day.D) The patient cleans with a warm washcloth after having a stool. |
Answer: A Fresh, thinned-skin peaches 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 to prevent perineal skin breakdown and infection.
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CHEMO 1) A patient is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy? a) Decrease in appetite.b) Drowsinessc) Spasms of the diaphragmd) Cough and shortness of breath |
Answer: d) Cough and shortness of breath RationaleCouch and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, drowsiness and spasms of the diaphragm may occur as a result of the chemotherapy; however they are not indicative of pulmonary toxicity.
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CHEMO 2) A nursing is assessing a female who is receiving her second administration of chemotherapy for breast cancer. When obtaining this client’s health history, what is the most important information the nurse should obtain? a) “Has your hair been falling out in clumps?” b) ”Have you had nausea or vomiting?” c) “Have you been sleeping at night?” d) “Do you have your usual energy level?” |
Answer: b) ” Have you had nausea or vomiting?”RationaleChemotherapy agents typically cause nausea and vomiting when not controlled by antiemetic drugs. Antineoplastic drugs attack growing normal cells, such as in the gastrointestinal tract. These drugs also stimulate the vomiting center brain. Hair loss, loss of energy, and sleep are important aspect of the health history, but not as critical as the potential for dehydration and electrolyte imbalance caused by nausea and vomiting.
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CHEMO 3) A client who is in the end stage of cancer is increasingly upset about receiving chemotherapy. Which of the following approaches by the nurse would likely be the most helpful in gaining the client’s cooperation? a) Telling the client how the treatment can be expected to help b) Describing the probable effect on missing a treatment c) Saying “Be a good client and don’t make the treatment any harder for yourself.”d) Promising to give a backrub when the treatment is complete. |
Answer: a) Telling the client how the treatment can be expected to help RationaleThe best course of action when the client has an outburst concerning treatment is to explain how the treatment is expected to help. Describing the effect if the client misses a treatment is a negative approach and may be threatening to the client. The client is likely to feel angry if told to be a “good client” during treatments. Offering to give the client a backrub does not give information to the client and may negatively reinforce the behavior.
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CHEMO 4) A client is concerned about losing the hair on their head as a result of chemotherapy. Which of the following responses from the nurse will be most helpful to the client? a) “The new growth of hair gray.”b) “The hair loss is temporary.” c) “New hair growth will be always the same texture and color as was before chemotherapy.”d) The client should avoid the use of wigs when possible. |
Answer: b) “The hair loss is temporary.” RationaleAlopecia from chemotherapy is temporary. The new hair will not be necessarily gray, but the texture and color of new hair growth may be different. The client who will be receiving chemotherapy should be encouraged to purchase a wig while they still have hair so they can match the color and texture of their hair. Loss of hair, or alopecia is a serious threat to self-esteem and should be addressed quickly before the treatment.
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CHEMO 5) A client diagnosed with cancer is receiving chemotherapy. The nurses should assess which of the following diagnostic values while the client is receiving chemotherapy?a) Bone marrow cellsb) Liver tissuesc) Heart tissuesd) Pancreatic enzymes. |
Answer: a) Bone marrow cellsRationaleThe fast-growing, normal cells most likely to be affected by certain cancer treatment are blood-forming cells in the bone marrow, as well as cells in the digestive tract, reproductive system, and hair follicles. Fortunately, most normal cells recover quickly when treatment is over. Bone marrow suppression (a decreased ability of the bone marrow to manufacture blood cells) is a common side effect of chemotherapy. A low white blood cell count (neutropenia) increases the risk of infection during chemotherapy, but other blood cells made in the bone marrow can be affected as well. Most cancer agents do not affect tissues and organs, such as the heart, liver, and pancreas.
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RADIATOIN 1) When giving care to the client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?a. Call the healthcare provider b. Reinsert the implant into the vagina c. Pick up the implant with gloved hands and flush it down the toilet d. Pick up the implant with long handled forceps and place it in a lead container |
Answer: D Rationale: In the event that a radiation source becomes dislodged the nurse would first encourage the client to lie still until the source has been placed in a safe closed container. The nurse would use a long handled forceps to place the source in the lead container that should be in the clients room. The nurse should then call the radiation oncologist and then document the event and the actions taken. It is not within the scope of nursing practice to insert a radiation implant.
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RADIATION 2) When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that applya. Limiting the time with the client to one hour per shift b. Keeping pregnant women out of the clients room c. Placing the client in a private room with a private bath d. Wearing a lead shield when providing direct client care e. Removing the dosimeter film badge when entering the clients room f. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client |
Answer: B,C,D Rationale: The time that the nurse spends in the room is 30 minutes per 8 hour shift. The client must be placed in a private room with a private bath. The nurse should wear a lead shield to reduce the transmission of radiation. The dosimeter film badge must be worn when in clients room. Children younger than 16 and pregnant women are not allowed in the clients room
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RADIATION 3) A female client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expecta. Hair loss b. Stomatitis c. Fatigue d. Vomiting |
Answer: C Rationale: Radiation therapy may cause fatigue, skin toxicities, and anorexia regardless of the treatment site. Hair loss, stomatitis, and vomiting are site-specific, not generalized, adverse effects of radiation therapy.
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RADIATION 4) Radiation protection is very important to implement when performing nursing procedures. When the nurse is not performing any nursing procedures what distance should be maintained from the client?a.1 feet b.2 feet c.2.5 feet d.3 feet |
Answer: D Rationale: The distance of at least 3 feet / 0.9 or 1 meter should be maintained when a nurse is not performing any nursing procedures
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RADIATION 5) Skin reactions are common in radiation therapy. Nursing responsibilities promoting skin integrity include the following except:a. Avoiding the use of ointments, powders and lotion to the area b. Using soft cotton fabrics for clothing c. Washing the area with a mild soap and water and patting it dry not rubbing it d. Avoiding direct sunlight or cold |
Answer: C Rationale: No soap should be used on the skin of the client undergoing radiation. Soap may cause dryness of the patient’s skin. Only water should be used in washing the area
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RADIATION 6) Contact of a client on radiation therapy should be limited only to how many minutes to promote safety of therapy personnel?a. 1 minute b. 3 minutes c. 5 minutes d. 10 minutes |
Answer: C Rationale: Principle of radiation protection follows the DTS system. Distance(D), Time(T), and Shielding(S). Distance- at least 3 feet should be maintained when a nurse is not performing any nursing procedures.Time- limit contact to 5 minutes each time. Shielding- use lead shield during contact with client
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Skin The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self care should be included in the teaching? A) wear sunscreen w/ protection factor of 10 or less when in the sun B) try to stay out of the sun between 300 to 500 daily C) perform thorough skin check monthly D) remember caps and long selves do not help prevent skin cancer |
C) perform a thorough skin check montnly
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SKIN The female client admitted for unrelated diagnoses asks the nurse to check her back b/c "it itches all the time in that one spot". When the nurse assess the client's back, the nurse notes an irregular-shaped lesion w/ some stabbed over areas surrounding the lesion. Which action should the nurse implement first A) notify HCP to check the lesions on rounds B) measure the lesion and note the color C) apply lotion to the lesion D) instruct the client to make sure the HCP checks the lesion |
B measure the lesion and note the color
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SKIN the nurse is caring for clients in an outpatient surgery clinic. which client should be assessed first? A) the client scheduled for a skin biopsy who is crying B) the client who had surgery 3 hours Ago and is sleeping C) the client who needs to void prior to discharge D) the client who has received discharged instruction and ready to go home |
A) the client scheduled for a skin biopsy who is crying
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SKIN Which client is at the greatest risk for the development of skin cancer? A) the African American male who lives in the northeast B) the elderly Hispanic female who moved from Mexico as a child C) the client who has a family history of basal cell carcinoma D) the client w/ fair complexion who cannot get a tan |
D) the client w/ fair complexion who cannot get a tan
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SKIN The middle aged client who has had two lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include? A) Teach the client that there is no more risk for cancer B) Refer the client to a prosthesis specialist for prosthesis C) instruct the client how to apply sunscreen to the area D) demonstrate care of surgical site |
D) demonstrate care of surgical site
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SKIN The nurse and an UAP are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP? A) stock the rooms w/ the equipment needed B) weight the client and position the clients for the examination C) discuss problems the client has experienced since the previous visit D) take biopsy specimens to the labratory |
C) discuss the problems the client has experienced since the previous visit
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SKIN The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma? A) the lesion is asymmetrical and has irregular borders B) the lesion has a waxy appearance w/ pearl like borders C) the lesion has a thickened and scaly appearance D) the lesion appeared as thickened area after an injury |
A) the lesion is asymmetrical and has irregular borders.
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SKIN The client has had a Squamous cell carcinoma removed from the lip. Which discharge instruction should the nurse provide? A) notify the HCP if a non-healing lesion develops around the mouth B) Squamous cell carcinoma tumors do not metastasize C) limit foods to liquid or soft consistency for one month D) apply heat to the area for 20 minutes every for hours |
A) notify the HCP if a non-healing lesion develops around the mouth.
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SKIN The male client diagnosed w/ AIDS states that he has developed a purple brown spot on his calf. Which action should the nurse do first? A) refer the client to HCP for a biopsy of the area B) assess the lesion for size, color, and symmetry C) discuss end of life decisions w/ client D) report sexually transmitted disease to the health department |
B) assess the lesion for size, color, and symmetry
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SKIN The nurse participating in a health fair is discussing malignant melanoma w/ a group of clients. Which information regarding the use of sunscreen is important to include? a) sunscreen is only needed during the hottest hours of the day b) toddlers should not have sunscreen applied to their skin c) sunscreen does not help prevent skin cancer d) the higher the number of the sunscreen, the more it blocks UV rays |
D) the higher the number of the sunscreen, the more it blocks UV rays
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