NR503 THE NURSING CARE OF ADULTS WITH MEDICAL AND SURGICAL HEALTH PROBLEMS Q&amp | Exams Nursing | Docsity (2024)

Download NR503 THE NURSING CARE OF ADULTS WITH MEDICAL AND SURGICAL HEALTH PROBLEMS Q&amp and more Exams Nursing in PDF only on Docsity! 1 THE NURSING CARE OF ADULTS WITH MEDICAL SURGICAL PROBLEMS TOPICS 1 .THE CLIENT AT RISK FOR CANCER 2 . THE CLIENT WITH PAIN 3. THE CLIENT WHO IS RECEIVING CHEMOTHERAPY 4. THE CLIENT WHO IS RECEIVING RADIATION THERAPY 5. THE CLIENT WHO REQUIRES SYMPTOM MANAGEMENT 6. THE CLIENT WHO IS COPING WITH LOSS ,GRIEF ,BEREAVEMENT,AND SPIRITUAL DISTRESS 7 .THE CLIENT EXPERIENCING PROBLEMS WITH SEXUALITY 8. ETHICAL AND LEGAL ISSUES RELATED TO CLIENTS WITH CANCER 9 .END OF LIFE CARE 10. MANAGING CARE QUALITY AND SAFETY 11. ANSWERS,RATIONALES,AND TEST TAKING STRATEGIES The Client at Risk for Cancer 1. The nurse is preparing an educational program on breast cancer for women at an African American community center. What information is important for the nurse to consider for the discussion? 1. African American women have the lowest rate of breast cancer. 2. Most African American women are diagnosed early in the disease process. 3. Breast cancer concerns vary between socio- economic levels of African American women. 4. African American women believe breast cancer is inevitable. 2. Which of the following clients is at highest RISK for colorectal cancer? 1. The client who smokes. 2. The client who eats a vegetarian diet. 3. The client who has been treated for Crohn’s disease for 20 years. 4. The client who has a family history of lung cancer. 3. A 21-year-old client undergoes bone marrow aspiration at the clinic to establish a diagnosis of possible lymphoma. Which statement made by the client demonstrates proper understanding of dis- charge teaching? Select all that apply. 1. “I will take Tylenol for pain.” 2. “I do not need to inspect the puncture site.” 3. “I will not be able to play basketball for the next 2 days.” 4. “I will take aspirin if I have pain.” 5. “I can apply an ice pack or a cold compress to the puncture site.” 2 4. A nurse is conducting a cancer risk screening program. Which of the following clients is at greatest risk for skin cancer? 1. 45-year-old physician. 2. 15-year-old high school student. 3. 30-year-old butcher. 4. 60-year-old mountain biker. 5. A client diagnosed with testicular cancer expresses concerns about fertility. The couple desires to eventually have a family and the nurse discusses the option of sperm banking. The nurse should inform the couple that sperm banking would need to be performed: 1. Before treatment is started. 2. Once the client is tolerating the treatment. 3. Upon completion of treatment. 4. When tumor markers drop to normal levels. 6. Carcinogenesis is irreversible in which of the following stages? 1. Progression stage. 2. Promotion stage. 3. Initiation stage. 4. Regression stage. 7. Cancer prevalence is defined as: 1. The likelihood cancer will occur in a lifetime. 2. The number of persons with cancer at a given point in time. 3. The number of new cancers in a year. 4. All cancer cases more than 5 years old 5 r rc 3 4e 16. The incidence and risk of cancer increase when smoking is combined with: 1. Asbestos exposure and alcohol consumption. 2. Ultraviolet radiation exposure and alcohol consumption. 3. Asbestos exposure and ultraviolet radiation exposure. 4. Alcohol consumption and human papilloma- virus (HPV) infection. 17. The nurse is assessing a 60- year- old male who has hoarseness. The nurse should conduct a focused assessment to determine: 1. Patterns of medication use and history of alcohol consumption. 2. Exposure to sun and family history of head and neck cancers. 3. Exposure to wood dust and a high-fat diet. 4. History of tobacco use and alcohol consumption 18. A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest? 1. Croissant, granola and peanut butter squares, whole milk. 2. Bran muffin, skim milk, stir-fried broccoli. 3. Granola, bagel with cream cheese, cauliflower salad. 4. Oatmeal, raisin cookies, baked potato with sour cream, turkey sandwich. 19. Which of the following is an environmental factor that increases the risk of cancer? 1. Gender. 2. Nutrition. 3. Immunologic status. 4. Age. 20. A client at risk for lung cancer asks why he is scheduled for a computed tomography (CT) scan as part of his initial workup. The nurse’s best response is which of the following? 1. “CT is far superior to magnetic resonance imaging for evaluating lymph node metastasis.” 2. “CT is noninvasive and readily available.” 3. “CT is useful for distinguishing small differences in tissue density and detecting nodal involvement.” 4. “CT can distinguish a malignant from a non- malignant adenopathy.” 21. Lifestyle influences that are considered risk factors for colorectal cancer include: 1. A diet low in vitamin C. 2. A high dietary intake of artificial sweeteners (Aspartame). 3. A high-fat, low-fiber diet. 4. Multiple sex partners. 6 22. The development of a culturally sensitive health education program for the socioeconomically disadvantaged requires the nurse to: 1. Locate the program at an existing government facility. 2. Integrate folk beliefs and traditions into the content. 3. Prepare materials in the primary language of the program sponsor. 4. Exclude community leaders from initial planning efforts. The Client with Pain 23. A client in a hospice program has increasing pain. The nurse and client collaborate to schedule analgesics to provide which of the following? 1. Doses of analgesic when pain is a “5” on a scale of 1–10. 2. Enough analgesia to keep the client semi- somnolent. 3. An analgesia-free period so that the client can carry out daily hygienic activities. 4. Around-the-clock routine administration of analgesics for continuous pain relief. 24. A client with pancreatic cancer is receiving morphine via a subcutaneous pump. The client is developing drug tolerance. The nurse understands that the client is: 1. Tolerating the medication well. 2. Showing addiction to morphine. 3. Requiring an increased dose. 4. Experiencing physical dependence. 25. A client with advanced ovarian cancer takes 150 mg of long-acting morphine orally every 12 hours for abdominal pain. When the client develops a small bowel obstruction, the physician discontinues the oral morphine and begins morphine 6 mg/ hour I.V. After calculating the equianalgesic conversion from oral to intravenous morphine, the nurse should: 1. Continue the oral morphine for one more dose after the I.V. morphine is started. 2. Contact the physician to suggest a higher equianalgesic dose of I.V. morphine. 3. Administer the morphine I.V. as ordered. 4. Clarify the order to recommend the initial morphine dose of 4 mg/hour. 26. A client is transferred to his room from the intensive care unit after a craniotomy for treatment of a malignant brain tumor in the occipital region. The nurse should question which of these orders? 1. 400 mg of ibuprofen (Motrin). 2. 500 mg of naproxen (Naprosyn). 3. Morphine sulfate. 4. Acetaminophen (Tylen 7 27. A 62-year-old female is taking long- acting morphine 120 mg every 12 hours for pain from metastatic breast cancer. She can have 20 mg of immediate-release morphine every 3 to 4 hours as needed for breakthrough pain. The physician should be notified if the client uses more than how many breakthrough doses of morphine in 24 hours? 1. Seven. 2. Four. 3. Two. 4. One. 28. Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which of the following systems? 1. Gastrointestinal. 2. Renal. 3. Pulmonary. 4. Cardiac. 29. The nurse is assessing a client with chronic pain. Which of the following is an expected response? 1. Elevated vital signs, physical inactivity, facial grimacing, and periods of anxiety. 2. Normal vital signs, physical inactivity, and normal facial expressions. 3. Normal vital signs, normal facial expressions, and moaning. 4. Elevated vital signs, grimacing, and depression. 30. Which of the following terms describes the condition of a client who requires an increase in dosage to maintain adequate analgesia? 1. Pseudoaddiction. 2. Physical dependence. 3. Psychological dependence. 4. Drug tolerance. 31. A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply. 1. Administers long-acting or sustained-release oral pain formula (OxyContin) regularly around-the-clock. 2. Administers immediate-release medication (oxycodone) for breakthrough pain. 3. Avoids long-acting opioids due to her concern about addiction. 4. Uses music for distraction as well as heat or cold in combination with medications. 5. Substitutes acetaminophen (Tylenol) to avoid tolerance to the medications. 6. Has her husband use a pain rating scale to measure the effectiveness at reaching his individual pain goal. 10 4. “Do you have your usual energy level?” 11 42. A 68-year-old male has been receiving monthly doses of chemotherapy for treatment of stage III colon cancer. He comes to the clinic for his fourth monthly dose. Which laboratory result(s) should be reported to the oncologist before the next dose of chemotherapy is administered? Select all that apply. 1. Hemoglobin of 14.5 g/dL. 2. Platelet count of 40,000/mm3. 3. Blood urea nitrogen (BUN) level of 12 mg/dL. 4. White blood cell count of 2,300/mm3. 5. Temperature of 101.2° F (38.4° C). 6. Urine specific gravity of 1.020. 43. A nurse is checking the laboratory results of a 52-year-old client with colon cancer admitted for fur- ther chemotherapy. The client has lost 30 lb (13.6 kg) since initiation of the treatment. Which laboratory result should be reported to the health care provider? 1. Blood glucose level of 95 mg/dL. 2. Total cholesterol level of 182 mg/dL. 3. Hemoglobin level of 12.3 mg/dL. 4. Albumin level of 2.8 g/dL. 44. The nurse is teaching a 17-year- old client and the client’s family about what to expect with high- dose chemotherapy and the effects of neutropenia. What should the nurse teach as the most reliable early indicator of infection in a neutropenic client? 1. Fever. 2. Chills. 3. Tachycardia. 4. Dyspnea. 45. A nurse is caring for a client who is under- going chemotherapy. Current laboratory values are noted on the chart. Which action would be most appropriate for the nurse to implement? 1. Wearing a protective gown and particulate respiratory mask when completing treat- ments. 2. Washing hands before and after entering the room. 3. Restricting visitors. 4. Contacting the physician for an order for hematopoietic factors such as erythropoietin (Epogen, Procrit). 12 LTea bs t oRre asut o lt r 15 51. A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of: 1. Hiatal hernia. 2. Stomatitis. 3. Radiation enteritis. 4. Esophagitis. 52. A 36-year-old female is scheduled to receive external radiation therapy and a cesium implant for cancer of the cervix. Which of the following state- ments would be most accurate to include in the teaching plan about the potential effects of radiation therapy on sexuality? 1. “You can have sexual intercourse while the implant is in place.” 2. “You may notice some vagin*l dryness after treatment is completed.” 3. “You may notice some vagin*l relaxation after treatment is completed.” 4. “You will continue to have normal menstrual periods during treatment.” 53. The nurse caring for a client who is receiv- ing external beam radiation therapy for treatment of lung cancer should assess the client for which of the following? 1. Diarrhea. 2. Improved energy level. 3. Dysphagia. 4. Normal white blood cell count. The Client Who Requires Symptom Management 54. A client receiving radiation to the head and neck is experiencing stomatitis. The nurse should recommend: 1. Evaluation by a dentist. 2. Alcohol-based mouth wash rinses. 3. Artificial saliva. 4. Vigorous brushing of teeth after each meal. 55. A client undergoing chemotherapy has a white blood cell count of 2300/mm3; hemoglobin of 9.8 g/dL; platelet count of 80,000/mm3 and potas- sium of 3.8. Which of the following should take priority? 16 1. Blood pressure 136/88. 2. Emesis of 90 mL. 3. Temperature 101° F (38.3° C). 4. Urine output 40 mL/hour. 17 The Client with Cancer 609 56. A client with bladder cancer has lost an estimated 500 mL blood in the urine. The client’s hemoglobin is 8.0 g/dL, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should: 1. Attach the packed cells to the existing 19G I.V. of normal saline solution using Y tubing. 2. Start an additional 22G I.V. site because the packed blood cells must be given in a sepa- rate line. 3. Attach the packed blood cells to the existing 22G I.V. of 5% dextrose using Y tubing. 4. Start an additional I.V. access device with a 22G Intracath. 57. A nurse is caring for a client 24 hours after he has undergone an abdominal- perineal resection for a bowel tumor. The client’s wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse? 1. Auscultate for bowel sounds. 2. Ask the client if he feels hunger or gas pains. 3. Consult the dietician. 4. Encourage the wife to bring the soup. 58. A nurse is making follow-up phone calls to clients being treated for cancer. Place the options below in the order of priority that the nurse should return the calls. 1. The client receiving chemotherapy who complains of a loss of appetite. 2. The client who underwent a mastectomy 2 weeks ago who called for information on the Reach for Recovery program. 3. The client receiving spinal radiation for bone cancer metastases who complains of urinary incontinence. 4. The client with colon cancer who has questions about a high-fiber diet. 59. Which of the following nursing interventions would be most helpful in making the respiratory effort of a client with metastatic lung cancer more efficient? 1. Teaching the client diaphragmatic breathing techniques. 2. Administering cough suppressants as ordered. 3. Teaching and encouraging pursed-lip breath- ing. 4. Placing the client in a low semi- Fowler’s posi- tion. 60. Which of the following should be included in the teaching plan for a cancer client who is expe- riencing thrombocytopenia? Select all that apply. 1. Use an electric razor. 2. Use a soft-bristle toothbrush. 3. Avoid frequent flossing for oral care. 4. Include an over-the-counter nonsteroidal anti- inflammatory (NSAID) daily for pain control. 5. Monitor temperature daily. 6. Report bleeding, such as nosebleed, pete- chiae, or melena, to a health care profes- sional. 61. A 28-year-old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse’s best response is which of the fol- lowing? 1. “Febrile reactions are caused when antibod- ies on the surface of blood cells in the trans- fusion are directed against antigens of the recipient.” 2. “Febrile reactions can usually be prevented by administering antipyretics and antihista- mines before the start of the transfusion.” 3. “Febrile reactions are rarely immune-medi- ated reactions and can be a sign of hemolytic transfusion.” 4. “Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and can occur during the blood transfusion.” 62. A 56-year-old client who recently had a right pneumonectomy for lung cancer is admitted to the oncology unit with dyspnea and fever. The nurse should: 1. Place the client on the left side. 2. Position the client for postural drainage. 3. Provide education on deep breathing exer- cises. 4. Instruct the client to maintain bed rest with bathroom privileges. 20 The Client with Cancer 611 72. Indicate on the illustration the area that correctly identifies the position of the distal tip of a central line that is inserted into the subclavian vessel. 73. A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radio- graphic results for confirmation of placement. The client becomes restless and dyspneic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent 76. A client with colon cancer had a left hemi- colectomy 3 weeks previously. The client is still having difficulty maintaining an adequate oral intake to meet metabolic needs for optimal healing. Which of the following nutritional support methods would be most appropriate? 1. Total parenteral nutrition through a central catheter. 2. I.V. infusion of dextrose. 3. Nasogastric feeding tube with protein supple- ment. 4. Jejunostomy for high caloric feedings. 77. A client with colon cancer undergoes surgi- cal removal of a segment of colon and creation of a sigmoid colostomy. What assessments by the nurse indicate the client is developing complications within the first 24 hours? Select all that apply. 1. Coarse breath sounds auscultated bilaterally at the bases. 2. Dusky appearance of the stoma. 3. No drainage in the ostomy appliance. 4. Temperature greater than 101.2° F (38.5° C). 5. Decreased bowel sounds. 78. A client receiving chemotherapy for meta- static colon cancer is admitted to the oncology unit due to several days of vomiting. Assessment find- ings include: irregular pulse of 120, blood pressure 88/48, respiratory rate of 14, serum potassium of 2.9 mEq/L, and arterial blood gas—pH 7.46, PCO 45, PO 95, bicarbonate level 29 breath sounds in the left lung. The nurse should further assess the client for: 1. An air embolus. 2. A pneumothorax. 3. A pulmonary embolus. 4. A myocardial infarction. 74. In setting goals for a client with advanced liver cancer who has poor nutrition, the nurse determines that which of the following is a realistic desired outcome for the client? The client will: 1. Have normalized albumin levels. 2. Return to ideal body weight. 3. Gain 1 lb every 2 weeks. 4. Maintain current weight. 75. The nurse administers a bolus tube feeding to a client with cancer. Which of the following nursing interventions is most appropriate to decrease the risk of aspiration? 1. Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours. 2. Place the client on the left side with the head of the bed at 45 degrees for 15 minutes. 3. Assist the client out of bed to sit upright in a chair for 1 hour. 4. Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes. 21 mEq2/L. Whic2h of the following interventions is appropriate for the nurse to administer to the client? 1. Oxygen at 4L per nasal cannula. 2. Potassium 40 mEq PO now. 3. 5% Dextrose in 0.45% Normal Saline with KCl 40 mEq/L at 125 mL/hour. 4. NaHCO3 75 mEq IV. 79. A 32-year-old female meets with the nurse on her first office visit since undergoing a left mastec- tomy. When asked how she is doing, the woman says her appetite is still not good, she is not getting much sleep because she doesn’t go to bed until her husband is asleep, and she is really anxious to get back to work. Which of the following nursing inter- ventions should the nurse explore to support the client’s current needs? 1. Call the physician to discuss allowing the client to return to work earlier. 2. Suggest that the client learn relaxation tech- niques for help with her insomnia. 3. Perform a nutritional assessment to assess for anorexia. 4. Ask open-ended questions about sexuality issues related to her mastectomy. 22 612 The Nursing Care of Adults with Medical and Surgical Health Problems 80. Which of the following client situations would require the most intensive nursing interven- tions for immobility? 1. A 38-year-old woman receiving internal radiation therapy for cervical cancer. 2. A 7-year-old boy with leukemia hospitalized for induction of high- dose chemotherapy. 3. A 75-year-old man with metastatic prostate cancer hospitalized for a pathologic fracture of the femur. 4. A 6-month-old undergoing surgery for place- ment of a central venous catheter. 81. A 52-year-old client with lung cancer tells the nurse that he has a low- grade fever (100.6° F [38.1° C]), nonproductive cough, and increasing fatigue. He completed the radiation therapy to the mass in his right lung and mediastinum 10 weeks ago and has a follow-up appointment to see the physician in 2 weeks. What is the most appropriate response by the telephone triage nurse? 1. Advise the client to take two acetaminophen tablets every 4 to 6 hours for 2 days and call back if his temperature increases to 101° F (38.3° C) or greater. 2. Advise the client that this is an expected side effect of the radiation therapy and to keep his appointment in 2 weeks. 3. Advise the client to come to the office to be examined today. 4. Advise the client to go to the nearest emer- gency department. 82. A client with malignant pleural effusions is complaining of dyspnea and chest pain. Place the following interventions that the nurse should per- form in the correct order of priority. exercise. 83. A client develops lymphedema after a left mastectomy with lymph node dissection. Which of the following should be included in the discharge teaching plan? Select all that apply. 1. Do not allow blood pressures or blood draws in the affected arm. 2. Avoid application of sunscreen on the left arm. 3. Use an electric razor for shaving. 4. Immobilize the left arm. 5. Elevate the left arm. 6. Perform hand pump exercises. 84. What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy? 1. Antibiotics will need to be taken for 1 to 2 weeks. 2. Arm exercises will get rid of the cellulitis. 3. Ice pack should be applied to the affected area for 20 minute periods to reduce swelling. 4. The right extremity should be lowered to improve blood flow to the forearm. 85. A 58-year-old male has just had a sclerosing agent instilled after chest tube drainage of a pleural effusion. The nurse should instruct the client to: 1. Lie still to prevent a pneumothorax. 2. Sit upright with arms on an overhead table to promote lung expansion. 3. Change position frequently to distribute the agent. 4. Lie on the side where the thoracentesis was done to hold pressure on the chest tube site. 86. After surgery for head and neck cancer, a client has a permanent tracheostomy. The nurse should teach the client and family about the impor- tance of : 1. Providing tracheostomy site care. 2. Addressing the psychosocial issues related to tracheostomy. 3. Observing for early signs and symptoms of skin breakdown around the tracheostomy site. 4. Using humidifiers to prevent thick, tenacious secretions. 87. A client has malignant pleural effusions. The nurse should conduct a focused assessment to deter- mine if the client has which of the following? Select all that apply. 1. Hiccups. 2. Weight gain. 3. Peripheral edema, 4. Chest pain. 5. Dyspnea. 6. Cough. 31. AEdmucinaitsetetrhemcolripehnitniensulfate 2 mg I.Va. nticipation of a thora- centesis. 2 4. A C p oa p c ly h o t x h y e g c e l n ien a t 2 on L d v e ia ep na b s r a e l athing cannula. 25 614 The Nursing Care of Adults with Medical and Surgical Health Problems 100. Which of the following variables is most important to assess when determining the impact of the cancer diagnosis and treatment modalities on a long-term survivor’s quality of life? 1. Occupation and employability. 2. Functional status. 3. Evidence of disease. 4. Individual values and beliefs. 101. A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. She says she usually has a bowel movement every day after her morning coffee. Bowel sounds are present in all four quadrants. She received 80 mg of doxorubicin hydrochloride (Adriamycin) 10 days ago. The nurse should contact the health care provider to request an order for which of the following? 1. A Fleet enema to stimulate peristalsis. 2. A soapsuds enema until clear. 3. An oral cathartic until the client has a bowel movement; then evaluate the need for daily stool softeners. 4. A daily stool softener for constipation and a mild opioid for abdominal discomfort. 102. A client with cancer has diarrhea and a nurs- ing diagnosis of Impaired skin integrity related to the frequent diarrhea. Which of the following nurs- ing interventions is appropriate for this diagnosis? 1. Discourage sitz baths because they promote bacterial growth. 2. Apply zinc oxide ointment to the rectal area after each bowel movement to protect the skin. 3. Apply a skin-barrier dressing daily to the rectal area to form a protective barrier. 4. Clean the rectal area with unscented soap and water after each bowel movement, rinse well, and pat dry. 103. Which of the following statements is most accurate regarding the long-term toxic effects of cancer treatments on the immune system? 1. Clients with persistent immunologic abnor- malities after treatment are at a much greater risk for infection than clients with a history of splenectomy. 2. The use of radiation and combination chemo- therapy can result in more frequent and more severe immune system impairment. 3. Long-term immunologic effects have been studied only in clients with breast and lung cancer. 4. The helper T cells recover more rapidly than 26 the suppressor T cells, which results in posi- tive helper cell balance that can last 5 years. 27 104. The nurse should expect single- donor plate- lets to be ordered for which of the following clients? 1. A client who is receiving multiple platelet transfusions. 2. A client who is deficient in coagulation fac- tors. 3. A client whose platelet count is greater than 50,000/mm3. 4. A client who is refractory to random-donor platelets. The Client Who Is Coping with Loss, Grief, Bereavement, and Spiritual Distress 105. A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the follow- ing nursing interventions will be most effective in helping the client cope? 1. Assume decision making for the client. 2. Encourage strict compliance with all treat- ment regimens. 3. Inform the client of all possible adverse treat- ment effects. 4. Identify available resources. 106. A daughter is concerned that her mother is in denial when discussing her diagnosis of breast cancer because she sometimes says that breast cancer isn’t that serious and changes the subject. The nurse informs the daughter that denial can be a healthy defense mechanism if it is used: 1. To permit her mother to seek unconventional treatments. 2. When making decisions about her care. 3. Alone and not in combination with other defense mechanisms. 4. To allow her mother to continue in her role as a mother. 107. A 45-year-old single mother of three teen- aged boys has metastatic breast cancer. Her parents live 750 miles away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children’s welfare during the treatment. When assessing the client’s present support systems, the nurse will be most concerned about the poten- tial problems with: 1. Denial as a primary coping mechanism. 2. Support systems and coping strategies. 3. Decision-making abilities. 4. Transportation and money for the boys. 30 114. The wife of a terminally ill client asks the nurse, “Why is my husband having frequent bowel movements if he is not eating?” Which of the follow- ing responses by the nurse informs the wife about the client’s condition? 1. “I know he is having frequent loose stools and it is distressing for you, but that’s just the way it is.” 2. “I don’t know when the bowels will shut down, but they will eventually.” 3. “The pain medication will eventually help to slow the process of bowel function.” 4. “The intestines still produce some waste products even when a person is not eating.” 115. The nurse formulates a nursing diagnosis of Spiritual distress related to advanced cancer dis- ease. An appropriate goal for the client would be to: 1. Start attending church or chapel services once a week. 2. Call a chaplain and set up an appointment for spiritual guidance. 3. Reflect on past accomplishments. 4. Participate in spiritual activities of the client’s choice. 116. A 72-year-old client with cancer needs assis- tance with paying hospital bills. The nurse should refer the client to a: 1. Bank representative. 2. Social worker. 3. Loan officer. 4. Representative of the hospital billing depart- ment. 117. The family members caring for a 72-year-old client who is near death from colon cancer are con- cerned about dehydration. What should the nurse tell them about dehydration at end of life? 1. The physician will make the decision regard- ing hydration therapy. 2. Dehydration may prolong the dying process. 3. Hydration is used only in extreme situations of dehydration. 4. Dehydration is expected during the dying process. 118. Which of the following actions should the nurse plan to do first when caring for a client who is experiencing spiritual distress? 1. Make a referral to a member of the clergy. 2. Explain the major beliefs of different religions. 3. Suggest reading material. 4. Help the client explore his or her own values and beliefs. 31 616 The Nursing Care of Adults with Medical and Surgical Health Problems 119. A nurse is caring for a client at home on hospice care for terminal renal cancer. People are calling the nurse to inquire about the client’s condi- tion. The nurse should tell the callers: 1. “Please call the oncologist.” 2. “The client is in a coma now.” 3. “Please call the client’s sister” 4. “The client is not expected to live much longer.” 120. A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which of the following changes in her husband’s behavior may confirm her fears? 1. Increased decisiveness. 2. Problem-focused coping style. 3. Increase in social interactions. 4. Disturbance in his sleep patterns. 121. The most appropriate suggestion for the hospice nurse to give a woman whose husband died 3 months ago and her three young children would be to: 1. Seek group counseling support for the three children. 2. Request individual counseling and medica- tion to manage depression. 3. Remind her gently that bereavement care before death minimizes grieving. 4. Continue her bereavement support through hospice. 122. Which of the following interventions will be most effective in improving transcultural communi- cations with oncology clients and their families? 1. Use touch to show concern and caring for the client. 2. Focus attention on verbal communication skills only. 3. Establish a rapport and listen to their con- cerns. 4. Maintain eye contact at all times. 123. A client with cancer verbalizes that he is afraid he won’t be able to cope with all the issues that will arise. The nurse can best support the cop- ing behaviors of a client with cancer by: 1. Helping the client identify available resources. 2. Encouraging compliance with treatment regi- mens. 3. Relieving the client of decision making as much as possible. 4. Assisting the client to prepare for adverse treatment effects. 124. The “I Can Cope,” “CanSurmount,” and “Reach to Recovery” programs are all designed to help cancer clients: 1. Choose treatment centers. 2. Find financial help. 3. Obtain home health care. 4. Cope with cancer. 125. A 56-year-old cancer survivor feels guilty at the “I Can Cope” meetings. The nurse can help him manage his feelings of guilt by pointing out that: 1. He is really angry at the terminally ill clients in the group. 2. He is experiencing very volatile emotions. 3. This is a spiritual response to his illness. 4. This is a normal reaction when surviving a life-threatening experience. 126. A 68-year-old client with colon cancer expe- riences an increase in his feelings of anxiety and depression and has suicidal ideation. He appears to be in great distress. The nurse realizes that he is at which stage in his disease? 1. Initiation of definitive treatment. 2. End of his first course of treatment. 3. End stage of his disease. 4. Recurrence of the disease. 127. A 57-year-old client has difficulty with mobility after cancer treatment therapies and states, “Why should I bother trying to get better? It doesn’t seem to make any difference what I do.” The nurse responds by helping the client establish reasonable activity goals, choose her own foods from the menu, and make choices about her daily activities. These interventions represent the nurse’s attempt to address which of the following nursing diagnoses? 1. Inefiective coping. 2. Powerlessness. 3. Risk prone health behavior. 4. Complicated grieving. 128. The nurse is aware that a 65- year-old widower whose only son is 500 miles away is at higher risk for psychosocial distress because the client: 1. Has been successful in dealing with stress all his life. 2. Does not have to deal with other stressors right now. 3. Is able to use denial as a coping mechanism. 4. Perceives he has minimal social support. 129. A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior is probably caused by: 1. Uncertainty and an underlying fear of recurrence. 2. The usual trajectory of a short-term illness. 3. A history of a behavioral illness. 4. The one-time crisis from learning of the diagnosis. 32 The Client with Cancer 617 130. A 42-year-old husband and father of a 7-year- old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife’s impending death from aggressive breast cancer. The nurse should: 1. Refer the family to pastoral care services. 2. Encourage the husband to come to terms with his own grief first. 3. Suggest that the children be told nothing until after death occurs. 4. Begin education about strategies for commu- nication with his children. 131. While talking to her husband, who is caring for their children, a 52- year-old client slams the phone down. She begins to cry and states that she is feeling guilty for being hospitalized. Which of the following interventions will best support the client emotionally? 1. Call the physician and ask for a psychiatry consultation. 2. Call the physician and request an antidepres- sant medication. 3. Sit with the client and help her acknowledge and discuss her feelings. 4. Sit with the client and encourage her to see the good side of the situation. 132. A 56-year-old female who is receiving radia- tion therapy tells the nurse that she feels inadequate as a wife and mother because she can no longer carry out her usual duties with the same energy as before. What recommendations should the nurse make to help the client cope with this situation? 1. Suggest that she reassign all household chores to other members of the family. 2. Suggest that she prioritize her activities and ask for help from friends and family. 3. Suggest that she ignore the household chores during the crisis period. 4. Tell her not to worry so much because every- one gets a little tired at this phase of the therapy. 133. A 66-year-old female who is usually metic- ulous about her appearance and dress arrives today for her 23rd day of radiation therapy. She appears disheveled and emotionally labile, and her responses to the usual questions are a little inap- propriate. Her heart rate is 124 bpm, her respira- tions are 32 breaths/minute, and her skin is cold and clammy. These findings would suggest that the nurse should further assess the client for which of the following conditions? 1. Schizophrenia. 2. Panic disorder. 3. Depression. 4. Delirium. 35 142. A registered nurse is assigning care on the oncology unit and assigns the client with Kaposi’s sarcoma and human immunodeficiency virus (HIV) infection to the licensed vocational nurse (LVN- LPN). The LVN-LPN states that she does not want to care for this client. How should the nurse respond? 1. “I will assign this client to another nurse.” 2. “I will help you take care of this client so you are confident with his care.” 3. “You seem worried about this assignment.” 4. “I will review blood and body fluid precau- tions with you.” 143. In an attempt to call public attention to the cancer survivor’s needs, a bill of rights was put forth by the: 1. American Cancer Society. 2. National Coalition of Cancer Survivors. 3. National Cancer Institute. 4. National Hospice Organization. 144. A 32-year-old teacher is concerned that she will lose her job if she requests a leave of absence to care for her father who is getting daily treatment for colon cancer in a city 300 miles away. Which legislative measure will likely protect her job during an extended illness? 1. Family Leave Act of 1993. 2. Americans with Disabilities Act of 1990. 3. Medicare Coverage for Catastrophic Illness Act of 1988. 4. Rehabilitation Act of 1973. 145. A 62-year-old woman thinks her husband’s rehabilitation needs have been unmet by his employer after his diagnosis and treatment of colon cancer. The nurse should give her information about: 1. The Americans With Disabilities Act of 1990. 2. Title V of the Rehabilitation Act of 1973. 3. The Civil Rights Act of 1964. 4. The Patient Self-Determination Act of 1991. 146. A client and nurse have established a goal for the client to be more autonomous. Which of the following situations indicates that the goal has been met? 1. The physician directs the client’s care. 2. The nurse provides the client with the facts and then allows the client to reach an unas- sisted decision. 3. The nurse respects a client’s choice not to know particular information. 4. The health care team makes health and treat- ment decisions. 36 End-of-Life Care 147. The family of a hospitalized client demon- strates understanding of the teaching about advance directives when they make which of the following statements? Select all that apply. 1. “Advance directives give instructions about future medical care and treatment.” 2. “If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken.” 3. “Ethics experts agree that the family is the sole deciding factor when the client is compe- tent.” 4. “Medical power-of-attorney gives primarily financial access to the designee.” 5. “Medical power-of-attorney or durable power- of-attorney for health care is a document that lists who can make health care deci- sions should a person be unable to make an informed decision for himself or herself.” 6. “Advance directives give details about the cli- ent’s past medical history.” 148. The nurse can be an important advocate for the client who is considering an alternative method of cancer treatment. Which of the follow- ing statements best demonstrates the nurse as client advocate? 1. The nurse will provide the information about standard therapies. 2. The nurse will monitor blood tests as indi- cated by the alternative therapy. 3. The nurse will document the client’s desire to try an alternative therapy. 4. The nurse will allow the client to make health care choices on her own but will assist in ensuring the client is fully informed when making those decisions. 149. After completing the nursing assessment for a client and family entering the palliative care pro- gram, the nurse should develop a teaching plan that includes an understanding of which of the following outcomes? Select all that apply. 1. Alteration in the family’s usual coping strategies. 2. Achievement of a dignified and respectful death. 3. Improvement in the client’s quality of life. 4. Provision of comfort during the dying process. 5. Provision of support for client and family. 6. Advocation for prolonging life while curing the disease. 37 The Client with Cancer 619 150. When a 62-year-old client and his family receive the initial diagnosis of colon cancer, the nurse can act as an advocate by: 1. Helping them maintain a sense of optimism and hopefulness. 2. Determining their understanding of the results of the diagnostic testing. 3. Listening carefully to their perceptions of what their needs are. 4. Providing them with written materials about the cancer site and its treatment. 151. A client who is dying of acquired immunode- ficiency syndrome (AIDS) is admitted to the inpatient psychiatric unit because he attempted suicide. His close friend recently died of AIDS. The client begins to talk about his feelings related to his illness and the loss of his friend. He begins to cry. Which of the following responses by the nurse would be most appropriate? 1. Give the client some tissues and tell him it is okay to cry. 2. Tell the client to stop crying and that every- thing will be okay. 3. Sort the client’s mail to distract the client. 4. Change the subject. 152. A 79-year-old male client is admitted again for heart failure and kidney failure. After completing his admission, the nurse is talking with the client’s wife, who expresses several concerns. She says, “I know he doesn’t want to die in a hospital, but it is so hard for me to take care of him at home. He said he doesn’t want any more treatment, but I’m not ready to let him go. We have so many arrangements to decide before he dies.” Which of the following statements by the nurse to the client’s wife would be most appropriate? Select all that apply. 1. “He’s not going to die that soon judging by his current symptoms.” 2. “What are your fears about your husband dying?” 3. “I can imagine that it is hard for you to care for him at home.” 4. “What do you and your husband know about advance directives?” 5. “We can discuss types of hospice and home care available.” 6. “What kind of arrangements do you think need to be made before he dies?” 153. A terminally ill client’s husband tells the nurse, “I wish we had taken that trip to Europe last year. We just kept putting it off, and now I’m furious that we didn’t go.” The nurse interprets the hus- band’s statement as indicating which of the follow- ing stages of adaptation to dying? 1. Anger. 2. Denial. 3. Bargaining. 4. Depression. 40 162. The nurse-manager on the oncology unit wants to address the issue of correct documentation of the effectiveness of analgesia medication within 30 minutes after administration. What should the nurse-manager do first? 1. Change the policy of documentation to 45 minutes. 2. Consult the pharmacist. 3. Consult the nurses on the evening shift where documentation of analgesia is the greatest problem. 4. Complete a brief quality improvement study and chart audit to document the rate of adher- ence to the policy and the pattern of docu- mentation over shifts. 163. A registered nurse (RN) instructs the unli- censed assistive personnel (UAP) to check the urine intake and output (I&O) on clients on the oncology unit at the end of the 8- hour shift. It is important for the nurse to instruct the UAP to do what? 1. Ask the clients if they are thirsty when calcu- lating the I&O. 2. Report back to the nurse immediately if any client has an output less than 240 mL. 3. Document the I&O results on the medical records. 4. Write the I&O results down for the nurse to give report to the next shift. 164. An 82-year-old elderly, alert, and oriented female with metastatic lung cancer is admitted to the medical- surgical unit for treatment of heart failure. She was given 80 mg of furosemide (Lasix) in the emergency department. Although the client is ambulatory, the unlicensed assistive personnel are concerned about urinary incontinence because the client is frail and in a strange environment. The nurse should instruct the unlicensed personnel to assist with implementing the nursing plan of care by: 1. Ordering adult diapers for the client so she will not have to worry about incontinence. 2. Requesting an indwelling urinary catheter to avoid incontinence. 3. Padding the bed with extra absorbent linens. 4. Placing a commode at the bedside and instructing the client in its use. 165. The nursing team on an oncology unit con- sists of a registered nurse (RN), a licensed vocational nurse (LVN-LPN), and unlicensed assistive person- nel (UAP). Which client should be assigned to the registered nurse? 1. A 52-year-old client with lung cancer admit- ted for acute dyspnea. 2. A 45-year-old client receiving tube feedings. 41 3. A 28-year-old client being evaluated for a bone marrow transplant. 4. A 65-year-old client diagnosed with endo- metrial cancer who underwent an abdominal hysterectomy 3 days ago. 42 The Client with Cancer 621 Answers, Rationales, and Test Taking Strategies The answers and rationales for each question follow below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills. For additional information about test- taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book. The Client at Risk for Cancer 1. 3. The nurse needs to consider the beliefs and concerns for all socioeconomic levels of African American women when providing education on breast cancer. Access to screening and care may differ. African American women are more likely to develop breast cancer and be diagnosed later in the disease process than Caucasian women. Not all African American women believe that breast cancer is inevitable. CN: Health promotion and maintenance; CL: Synthesize 2. 3. Clients over age 50 who have a history of inflammatory bowel disease are at risk for colon cancer. The client who smokes is at high risk for lung cancer. While the exact cause is not always known, other risk factors for colon cancer are a diet high in animal fats, including a large amount of red meat and fatty foods with low fiber, and the pres- ence of colon cancer in a first- generation relative. CN: Reduction of risk potential; CL: Analyze 3. 1, 3, 5. Acetaminophen (Tylenol) is a safer analgesic than aspirin in order to avoid bleed- ing. Contact sports or trauma to the site should be avoided. Cool compresses should limit swelling and bruising. The puncture site should be inspected every 2 hours for bleeding or bruising during the first 24 hours. 45 Tail of Spence Upper inner 3 Upper outer 4 1 2 Lower inner Lower outer 11. The upper outer quadrant is the area of the breast in which most breast tumors are found. This area should be palpated thoroughly. Although breast tumors can be found in any area of the breast, including the nipple, the tumors are most often in the upper outer CN: Health promotion and maintenance; CL: Apply 12. 3. The American Cancer Society guidelines (2004) state that a Pap smear and pelvic examina- tion should be done 3 years after a woman first has vagin*l intercourse, but no later than 21 years of age. Annual Pap smears are recommended only for clients at risk and not for the general female popula- tion. After three or more consecutive annual exami- nations with normal findings, the Pap smear may be performed less frequently at the discretion of the physician. Colposcopy is indicated for an abnormal Pap smear, not a negative Pap smear. CN: Health promotion and maintenance; CL: Apply 13. 3. Because more than 50% of the cancers occur in people who are older than age 65, the single most important factor in determining risk would be age. CN: Health promotion and maintenance; CL: Apply 14. 3. Evidence suggests that a high- fat diet increases the risk of several cancers, including breast, colon, and prostate cancers. Ovarian, lung, and liver cancers have not been linked to a high-fat diet. CN: Health promotion and maintenance; CL: Apply 46 15. 4. The client is at increased risk for develop- ment of lung, skin, or breast cancer. Consequently, the most urgent changes in behavior should include smoking cessation, protection from the sun, and weight loss. Decreasing alcohol consumption is cer- tainly desirable, as is improving overall nutritional intake (e.g., eating low-fat foods, increasing fiber) but is not the most urgent behavior change for this client. CN: Health promotion and maintenance; CL: Synthesize 16. 1. Asbestos and alcohol, when combined with smoking, produce a synergistic effect and result in increased cancer risk and incidence. Ultra- violet radiation exposure is associated with skin cancer. HPV exposure is associated with cervical cancer. However, the risks of contracting these types of cancer are not markedly increased when com- bined with smoking. CN: Health promotion and maintenance; CL: Apply 17. 4. Although exposure to the sun increases the risk of skin cancers and family history is signifi- cant in the development of some types of cancer, heavy tobacco use and alcohol intake have a syner- gistic effect and increase the risk and incidence of head and neck cancers. Patterns of medication use, exposure to wood dust, and a high-fat diet are not associated with an increased risk and incidence of head and neck cancers. CN: Health promotion and maintenance; CL: Analyze 18. 2. High-fiber, low-fat diets are recommended to reduce the risk of colon cancer. Stir-frying, poach- ing, steaming, and broiling are all low-fat methods to prepare foods. Croissants are made of refined flour. They are also high in fat, as are peanut butter squares and whole milk, granola, cream cheese, and sour cream. CN: Health promotion and maintenance; CL: Apply 19. 2. Environmental factors include place of residence, nutrition, occupation, personal hab- its, iatrogenic factors, and physical environment. Gender, immunologic status, and age are individual factors. CN: Health promotion and maintenance; CL: Apply 20. 3. CT scanning is the standard noninvasive method used in a workup for lung cancer because it can distinguish small differences in tissue density and can detect nodal involvement. CT is comparable to magnetic resonance imaging in evaluating lymph 47 The Client with Cancer 623 node metastasis. CT is noninvasive and usually available, but these are not the main reasons for its use. CT can distinguish malignancy in some situa- tions only. CN: Physiological adaptation; CL: Synthesize 21. 3. A high-fat, low-fiber diet is a risk factor for colorectal cancer. A diet low in vitamin C, use of artificial sweeteners, and multiple sex partners are not considered risk factors for colorectal CN: Health promotion and maintenance; CL: Analyze 22. 2. Strategies to reach the socioeconomically disadvantaged should include incorporating the folk beliefs and traditions of the target population into the program. Identification of a centrally located build- ing with available access by the target population, use of materials in the native or primary language of the target population, and involvement by the com- munity leaders will also help the program succeed. CN: Health promotion and maintenance; CL: Synthesize The Client with Pain 23. 4. The desired outcome for management of pain is that the client’s or family’s subjective report of pain is acceptable and documented using a pain scale; the goal is that behavioral and physiologic indicators of pain are absent around the clock. The nurse and client/family should develop a systematic approach to pain management using information gathered from history and a hierarchy of pain mea- surement. Pain should be assessed at frequent inter- vals. The client should not wait to receive medica- tion until the pain is midpoint on the pain scale, nor should the client receive so much pain medication that he or she is not alert. Continuous pain relief is the goal, not just during particular periods during CN: Basic care and comfort; CL: Synthesize 24. 3. Tolerance develops from taking opioids over an extended period. It is characterized by the need for an increased dose to achieve the same degree of analgesia. Addiction is characterized by a drive to take the medication for the psychic effect rather than the therapeutic effect. Physical depen- dence is a response to ongoing exposure to a medi- cation manifested by withdrawal symptoms when discontinued abruptly. CN: Pharmacological and parenteral therapies; CL: Analyze 50 pain can be controlled. The nurse and client can collaborate to reduce aggravating factors; however, the goal will ultimately be to reduce the intensity of the pain. CN: Basic care and comfort; CL: Analyze 34. 2. There is a 1:3 ratio with equianalgesic dos- ing of I.V. to oral morphine; therefore, the physician should order three times the I.V. dose. CN: Pharmacological and parenteral therapies; CL: Apply 35. 4. Normeperidine is a potent long- acting metabolite, which can cause central nervous system (CNS) stimulation and seizures. Meperidine is a short-acting drug and must be given in more fre- quent intervals and may require increased dosages for effectiveness. Mixed agonist- antagonists act competitively at different pain receptor sites. It is generally accepted by cancer pain experts that opioid agonist-antagonist drugs have very limited usefulness in cancer pain management because of their tendency to induce opioid withdrawal and cause severe CNS adverse effects. Meperidine does not have a higher potential for abuse than other opi- oids. There are other routes of meperidine admin- istration, so the route of administration is not the limiting factor. CN: Pharmacological and parenteral therapies; CL: Apply 36. 2. Tolerance to an opioid occurs when a larger dose of the analgesic is needed to provide the same level of pain control. The risk of addiction is low with opioids to treat cancer pain. There are no data to support that this client is experiencing with- drawal. Although the client may have experienced a placebo effect at one time, placebo effects tend to diminish over time, especially in regard to chronic cancer pain. CN: Pharmacological and parenteral therapies; CL: Analyze 37. 2. The regular administration of analgesics provides a consistent serum level of medication, which can help prevent breakthrough pain. There- fore, taking the prescribed analgesics on a regular schedule is the best way to manage chronic cancer- related pain. There is little risk for the client with cancer- related pain to become addicted. Sleeping 12 to 16 hours a day would not allow the client to participate in usual daily activities or preferred activities. CN: Pharmacological and parenteral therapies; CL: Synthesize 51 The Client with Cancer 625 The Client Who Is Receiving Chemotherap y 38. 3. Resources should be provided for acquir- ing a wig since it is easier to match hair style and color before hair loss begins. The client has expressed negative feelings of self image with hair loss. Excessive shampooing and manipulation of hair will increase hair loss. Hair usually grows back in 3 to 4 weeks after the chemotherapy is finished, however new hair may have a new color or texture. A wig, hairpiece, hat, scarf, or turban can be used to conceal hair loss. Social isolation should be avoided and the client should be encouraged to socialize with others. CN: Pharmacological and parenteral therapies; CL: Synthesize 39. 4. A side effect of vincristine is constipa- tion and a bowel protocol should be considered. Imodium is used to treat diarrhea. Fluids should be encouraged, along with high fiber foods to prevent constipation. CN: Pharmacological and parenteral therapies; CL: Synthesize 40. 3. Carbohydrates are the first substance used by the body for energy. Proteins are needed to maintain muscle mass, repair tissue, and main- tain osmotic pressure in the vascular system. Fats, in a small amount, are needed for energy produc- tion. Chicken, green beans, and cottage cheese are the best selection to provide a nutritionally well- balanced diet of carbohydrate, protein, and a small amount of fat. Cereal with milk and strawberries as well as toast, gelatin dessert, and cookies have a large amount of carbohydrates and not enough protein. Steak and french fries provide some carbo- hydrates and a good deal of protein; however, they also provide a large amount of fat. CN: Health promotion and maintenance; CL: Synthesize 41. 2. Chemotherapy agents typically cause nausea and vomiting when not controlled by anti- emetic drugs. Antineoplastic drugs attack rapidly growing normal cells, such as in the gastrointestinal tract. These drugs also stimulate the vomiting center in the brain. Hair loss, loss of energy, and sleep are important aspects of the health history, but not as critical as the potential for dehydration and electro- lyte imbalance caused by nausea and vomiting. CN: Pharmacological and parenteral therapies; CL: Analyze 42. 2, 4, 5. Chemotherapy causes bone marrow suppression and risk of infection. A platelet count of 40,000/mm3 and a white blood cell count of 52 626 The Nursing Care of Adults with Medical and Surgical Health Problems 2,300/mm3 are low. A temperature of 101.2° F (38.4° C) is high and could indicate an infection. Further assessment and examination should be per- formed to rule out infection. The BUN, hemoglobin, and specific gravity values are normal. CN: Reduction of risk potential; CL: Analyze 43. 4. The nurse must recognize that an albumin level of 2.8 g/dL indicates catabolism and potential for malnutrition. Normal albumin is 3.5 to 5.0 g/dL; less than 3.5 indicates malnutrition. The other labo- ratory results are normal. CN: Reduction of risk potential; CL: Analyze 44. 1. Fever is an early sign requiring clinical intervention to identify potential causes. Chills and dyspnea may or may not be observed. Tachycardia can be an indicator in a variety of clinical situations when associated with infection; it usually occurs in response to an elevated temperature or change in cardiac CN: Reduction of risk potential; CL: Analyze 45. 2. Chemotherapy causes myelosuppression with a decrease in red blood cells (RBCs), WBCs, and platelets. This client’s data demonstrate neutropenia, placing the client at risk for infection. An ANC of 500 to 1,000/mm3 indicates a moderate risk of infec- tion; an ANC of less than 500/mm3 indicates severe neutropenia and a high risk of infection. When the WBC count is low and immature WBCs are present, normal phagocytosis is impaired. Precautions are implemented to protect the client from life-threaten- ing infections. These may be instituted when ANC is less than 1,000/mm3. Hand washing is the single best way to avoid the spread of infection. It is not necessary to wear a gown and mask to take care of this client. It is also not necessary to restrict visitors; however, the client’s visitors should be screened to avoid exposing the client to possible infections. Epogen or Procrit are used for stimulating RBCs, not WBCs. Granulocyte colony-stimulating factors or granulocyte macrophage colony- stimulating factors are useful for treating neutropenia. CN: Safety and infection control; CL: Synthesize 46. 1. The role of the nurse is to assess what substances or medications the client is using and to document and inform other members of the health care team. It is very important to encourage the client to keep the physician informed of all therapeutic agents, medications, and supplements she is using, to avoid adverse interactions. It is not appropriate for the nurse to suggest that the client choose either Western or alternative therapies or to discourage 55 27 The Client with Cancer 6 Surveillance for bleeding is important with the low hemoglobin and platelet count, however, the high blood pressure does not indicate bleeding. Vomit- ing is a side effect of chemotherapy and should be treated. The urine output and potassium are within normal limits. CN: Physiological adaptation; CL: Synthesize 56. 1. The packed cells should be administered using a central catheter or 19G needle. Y tubing is used and the normal saline solution is used to keep the vein open when the blood transfusion is com- plete. Blood is not compatible with dextrose because dextrose may cause blood coagulation. Blood prod- ucts should be given with normal saline solution. A blood filter must be used for all blood products to filter out sediment from stored blood products. It is not necessary to add another I.V. access. CN: Pharmacological and parenteral therapies; CL: Synthesize 57. 1. The nurse should perform a thorough assessment of the abdomen and auscultate for bowel sounds in all four quadrants. Clients who have gas- trointestinal surgery may have decreased peristalsis for several days after surgery. The nurse should check the abdomen for distention and check with the client and the medical record regarding the pas- sage of flatus or stool. Consulting a dietician would be inappropriate because the client must be kept on nothing-by-mouth status until bowel sounds are present. The nurse should explain to the wife that it is too soon after surgery for her husband to eat. CN: Reduction of risk potential; CL: Synthesize 58. 3. The client receiving spinal radiation for bone cancer metastases who complains of urinary incontinence. 1. The client receiving chemotherapy who complains of a loss of appetite. 4. The client with colon cancer who has ques- tions about a high-fiber diet. 2. The client who underwent a mastectomy 2 weeks ago who called for information on the Reach for Recovery program. Using Maslow’s hierarchy of needs to set priori- ties, the nurse should first call the client with bone cancer metastases to the spine because this client is at risk for compression, damage, or severing of the spinal cord. The nurse should evaluate the client 56 628 The Nursing Care of Adults with Medical and Surgical Health Problems immediately for urinary incontinence, paralysis, difficulty ambulating, and possible weakness or loss of motor function. The nurse should next call the client with loss of appetite to assess weight loss and suggest ways to increase the appetite. The client with colon cancer requires assistance with diet plan- ning, also a physiologic need, but this client is not at high risk for weight loss. Lastly, the nurse should obtain information on Reach to Recovery and return the call to the client with a mastectomy. The needs of this client are the least urgent. CN: Reduction of risk potential; CL: Synthesize 59. 3. For clients with obstructive versus restric- tive disorders, extending exhalation through pursed- lip breathing will make the respiratory effort more efficient. The usual position of choice for this client is the upright position, leaning slightly forward to allow greater lung expansion. Teaching diaphrag- matic breathing techniques will be more helpful to the client with a restrictive disorder. Administering cough suppressants will not help respiratory effort. A low semi-Fowler’s position does not encourage lung expansion. Lung expansion is enhanced in the upright position. CN: Basic care and comfort; CL: Synthesize 60. 1, 2, 3, 6. Thrombocytopenia places the client at risk for bleeding. Therefore, electric razors will reduce the potential for skin nicks and bleeding. Oral hygiene should be provided with a soft tooth- brush and with minimal friction to gently clean without trauma. Clients should be instructed to read labels on all over- the- counter medications and avoid medication such as aspirin or NSAIDs due to their effect on platelet adhesiveness. Clients should evaluate mucous membranes, skin, stools, or other sources of potential bleeding. Monitoring tempera- ture may be an important part of assessment but is focused on neutropenia instead of the problem of thrombocytopenia. CN: Reduction of risk potential; CL: Create 61. 2. The administration of antipyretics and antihistamines before initiation of the transfusion in the frequently transfused client can decrease the incidence of febrile reactions. Febrile reactions are immune-mediated and are caused by antibodies in the recipient that are directed against antigens pres- ent on the granulocytes, platelets, and lymphocytes in the transfused component. They are the most common transfusion reactions and may occur with onset, during transfusion, or hours after transfusion is completed. CN: Pharmacological and parenteral therapies; CL: Synthesize 57 62. 3. The fever and dyspnea suggest a respiratory infection. Education on deep breathing exercises or incentive spirometry, elevating the head of the bed, and getting out of bed to a chair is necessary to promote lung expansion. When in bed, positioning the client with good lung down should be avoided, since this impedes expansion of the only lung. Postural drainage positioning will lower the head of bed and increase dyspnea. CN: Physiological adaptation; CL: Synthesize 63. 2. An individualized exercise program will increase stamina and endurance. Weight lifting may be too vigorous. Neupogen is used to increase white blood cells and is not applicable in this situation. Decreased hemoglobin and hematocrit predisposes the client to fatigue due to decreased oxygen avail- ability. Bed rest causes muscle atrophy, adding to fatigue, and promotes DVT formation. CN: Health promotion and maintenance; CL: Synthesize 64. 1. Dietary suggestions to reduce adverse effects of cancer and cancer therapies include a soft, bland diet low in fat and sugar. Frequent, small meals are usually better tolerated. It is not necessary to restrict the diet to cold foods. Fluid intake should be encouraged to avoid dehydration. CN: Basic care and comfort; CL: Synthesize 65. 4. The use of diet modification is a conserva- tive approach to treat the terminally ill or hospice clients who have nausea and vomiting related to bowel obstruction. Osmotic laxatives would be harder for the client to tolerate. An NG tube is more aggressive and invasive. I.V. antiemetics are also invasive. The hospice philosophy involves comfort and palliative care for the terminally ill. CN: Basic care and comfort; CL: Synthesize 66. 3. Repositioning the client, elevating the head of the bed, and providing a cool compress are comfort interventions consistent with the concept of palliative care of the dying. Directing the unlicensed personnel to assess vital signs focuses on the dying process, not the client. Suctioning may not benefit the client and is considered invasive and uncomfort- able. Telling the wife an intervention is not needed discounts her judgment and concerns. CN: Basic care and comfort; CL: Synthesize 67. 2. Alopecia from chemotherapy is temporary. The new hair will not be necessarily gray, but the texture and color of new hair growth may be dif- ferent. Clients who will be receiving chemotherapy 60 The Client with Cancer 629 declotting regimen (Abbokinase). The nurse should not administer any drug if the I.V. line is not open or does not have an adequate blood return. CN: Pharmacological and parenteral therapies; CL: Create 72. The distal tip of a central line lies in the superior vena cava or right atrium. CN: Pharmacological and parenteral therapies; CL: Apply 73. 2. The client is exhibiting signs and symp- toms of a pneumothorax from the insertion of the subclavian venous catheter. Although it is possible that the client suffered an air embolus during the procedure, and the client is at risk for pulmonary emboli because of his immobility, absent breath sounds immediately after insertion of a subclavian line are strongly suggestive of a pneumothorax. Uni- lateral absent breath sounds are not associated with a myocardial infarction. CN: Physiological adaptation; CL: Analyze 74. 4. An appropriate and realistic outcome would be for the client to maintain current weight or not lose weight. It is unrealistic to expect that the client with advanced liver cancer will have normal albumin levels or will be able to gain weight. CN: Basic care and comfort; CL: Synthesize 75. 3. As long as the client is able to get out of bed, the preferred position and time frame for preventing aspiration after a bolus tube feeding is sitting upright out of bed in a chair for 30 to 60 min- utes. Placing the client on the right, not the left, side may facilitate gastric emptying, but this is not the 61 preferred position. Elevating the bed 30 degrees decreases the risk of aspiration, but this elevation must be maintained for at least 45 to 60 minutes. CN: Basic care and comfort; CL: Synthesize 62 630 The Nursing Care of Adults with Medical and Surgical Health Problems 76. 1. Total parenteral nutrition solutions supply the body with sufficient amounts of dextrose, amino acids, fats, vitamins, and minerals to meet metabolic needs. Clients who are unable to tolerate adequate quantities of foods and fluids and those who have had extensive bowel surgery may not be candidates for enteral feedings. The nurse would anticipate total parenteral nutrition via central catheter to pro- mote wound healing. I.V. dextrose does not supply all the nutrients required to promote wound heal- ing. CN: Pharmacological and parenteral therapies; CL: Synthesize 77. 1, 2, 4. Elevated temperature in the first 24 hours along with coarse breath sounds may indicate a respiratory complication or the result of general anesthesia. Use of incentive spirometry and increasing activity would be key interventions. A healthy stoma will be beefy red. A dusky appear- ance of the stoma indicates decreased blood sup- ply and is of concern. It is not uncommon to have decreased bowel sounds initially after gastrointesti- nal surgery. In addition, it usually will take time for the ostomy to function. CN: Reduction of risk potential; CL: Analyze 78. 3. The vital signs suggest that the client is dehydrated from the vomiting. I.V. fluids should be initiated with the addition of potassium. Oral potassium should be avoided since the client is vomiting and potassium is irritating to the stomach. Oxygen is not indicated at this time since the PO2 is 95. The client with a metabolic alkalosis should not receive sodium bicarbonate; this will increase the alkalosis. CN: Physiological adaptation; CL: Synthesize 79. 4. The content of the client’s comments sug- gests that she is avoiding intimacy with her husband by waiting until he is asleep before going to bed. Addressing sexuality issues is appropriate for a client who has undergone a mastectomy. Rushing her return to work may debilitate her and add to her exhaustion. Suggesting that she learn relaxation techniques for help with her insomnia is appro- priate; however, the nurse must first address the psychosocial and sexual issues that are contributing to her sleeping difficulties. A nutritional assessment may be useful, but there is no indication that she has anorexia. CN: Psychosocial adaptation; CL: Synthesize 80. 3. Although each client listed is at some risk of complication secondary to immobility, the 65 The Client with Cancer 631 90. 4. Petechiae are tiny purplish, hemorrhagic spots visible under the skin. Petechiae usually appear when platelets are depleted. Bleeding gums or oozing of blood may accompany the petechiae, and the client should seek medical assistance imme- diately. Increasing iron in the diet will not improve the platelet count. Lotion will not treat the pete- chiae. Elevating the legs will not cause the petechiae to disappear. CN: Physiological adaptation; CL: Synthesize 91. 3. Lymphedema after breast cancer surgery is the accumulation of lymph tissue in the tissues of the upper extremity extending down from the upper arm. It may occur at any time after surgery in women of any age. It is caused by the interrup- tion or removal of lymph channels and nodes after axillary node dissection. Removal results in less efficient filtration of lymph fluid and a pooling of lymph fluid in the tissues on the affected side. Treat- ments or interventions should be instituted as soon as lymphedema is noted to prevent or reduce further progression. Range-of-motion exercises, elevation, and avoidance of injury in the affected arm are important when completing client teaching. Lym- phoma is not caused by failure to remove all cancer cells. Lymphedema can occur after any surgery that disrupts lymph flow, not just radical mastectomy. CN: Reduction of risk potential; CL: Synthesize 92. 3. Infection may occur in a client with lymphedema because of the stagnant accumulated fluid, which becomes an excellent medium for bacteria growth. Capillary permeability, not fragility, increases fluid in lymphedema. Myelosuppression is not related to lymphedema, only to a neoplastic disease or sequela to treatment of neoplastic dis- ease. Increased use of the extremity may also cause increased accumulation of fluid, but it is not a direct cause of cellulitis and lymphangitis. CN: Reduction of risk potential; CL: Apply 93. 3. Redness, warmth, and swelling are all signs of infection. Treatment with antibiotics is usually indicated. Infection usually increases fluid accumulation and could worsen the lymphedema. Warm compresses could also increase fluid accu- mulation. Elevation will not treat the infection. It is critical that the client not delay treatment. CN: Reduction of risk potential; CL: Synthesize 94. 4. Fever is most commonly related to infec- tion. In a neutropenic client, fever frequently occurs in the absence of the usual clinical signs 66 632 The Nursing Care of Adults with Medical and Surgical Health Problems and symptoms of infection. Inadequate nutrition or antiemetic therapy resistance would not result in fever. Fever is not usually expected with most che- motherapy drugs. CN: Physiological adaptation; CL: Analyze 95. 2. Nine days after chemotherapy, one would expect the client to be immunocompromised. The clinical signs and symptoms of shock reflect changes in cardiac function, vascular resistance, cellular metabolism, and capillary permeability. Low-grade fever, tachycardia, and chills may be early signs of shock. The client with signs and symptoms of impending septic shock may not have decreased oxygen saturation levels. Oliguria and hypotension are late signs of shock. Urine output can be initially normal or CN: Pharmacological and parenteral therapies; CL: Analyze 96. 3. Prioritizing physical activities helps to conserve energy, which promotes adaptation to fatigue. The client should learn to take short naps or short rest periods during the day for additional energy conversation. Increased fluid intake is impor- tant but may interrupt rest periods by causing fre- quent urination. Limiting intake of high-fiber foods can add to constipation, which may be a problem because of inactivity in fatigued clients. CN: Basic care and comfort; CL: Synthesize 97. 4. Most hospitalized persons are at risk for sleep disturbances. Psychological issues (such as anxiety and depression) and pain are related to sleep deprivation. Social, nutritional, and cultural issues are not necessarily associated with sleep dis- turbances. CN: Psychosocial adaptation; CL: Apply 98. 4. Nursing interventions to decrease the discomfort of pruritus include those that prevent vasodilation, decrease anxiety, and maintain skin integrity and hydration. Medicated baths with salicylic acid or colloidal oatmeal can be soothing as a temporary relief. The use of antihistamines or topical steroids depends on the cause of the pruri- tus, and these agents should be used with caution. Using silk sheets is not a practical intervention for the hospitalized client with pruritus. CN: Basic care and comfort; CL: Apply 99. 4. Use of deodorant or fragrant soaps is drying to the skin. Cotton clothing gives the least irritation to skin. A cool, humidified environment adds to the client’s comfort as well as providing 67 hydration for skin comfort. Fluid intake of 3,000 mL day is recommended for adequate hydration. CN: Basic care and comfort; CL: Analyze 100. 4. Individuals with cancer have various cultural values and beliefs that help them cope with the cancer experience. Quality of life cannot be evaluated solely by quantifiable factors such as employability, functional status, or evidence of disease. It must be evaluated by the survivors within the context of their subjective and individual values and beliefs. CN: Psychosocial adaptation; CL: Analyze 101. 3. Constipation lasting 3 days or longer is unusual in this client and warrants immediate action. However, because the client had chemother- apy with doxorubicin (Adriamycin) 10 days ago, she is susceptible to infection and should avoid rectal medications and treatments. Abdominal discomfort secondary to constipation will be relieved after the client has a bowel movement; an opioid would con- tribute to the constipation. CN: Pharmacological and parenteral therapies; CL: Synthesize 102. 4. The rectal area needs to be cleaned and gently dried after each bowel movement to prevent skin breakdown and inhibit growth of bacteria. Sitz baths are appropriate because they promote comfort. Zinc oxide ointment does form a protective skin barrier, but it makes it difficult to thoroughly clean the perirectal area of feces and increases the risk of infection, as do skin-barrier dressings. CN: Safety and infection control; CL: Synthesize 103. 2. Studies of long-term immunologic effects in clients treated for leukemia, Hodgkin’s disease, and breast cancer reveal that combination treat- ments of chemotherapy and radiation can cause overall bone marrow suppression, decreased leukocyte counts, and profound immunosuppres- sion. Persistent and severe immunologic impairment may follow radiation and chemotherapy (especially multiagent therapy). There is no evidence of greater risk of infection in clients with persistent immuno- logic abnormalities. Suppressor T cells recover more rapidly than the helper T cells. CN: Pharmacological and parenteral therapies; CL: Apply 104. 1. Clients who receive multiple platelet transfusions may form antibodies against many foreign antigens, thereby decreasing platelet response. Single-donor platelets are drawn from a single donor, decreasing the number of possible foreign antigens and increasing platelet response 70 634 The Nursing Care of Adults with Medical and Surgical Health Problems 113. 3. Mental changes and decreased level of consciousness are common in the dying process. Comments that allude to travel, trips, or going somewhere are also common. Suggesting that the client be sedated ignores the husband’s question about what his wife is experiencing. Suggesting that the client is fighting death and that the husband should leave her alone is inappropriate and denies the husband time to spend with his wife. Although decreased circulation and lack of oxygen may cause delirium, delirium is not the norm in the dying process. CN: Psychosocial adaptation; CL: Synthesize 114. 4. It is important to give factual information to answer a loved one’s questions and concerns. Stating, “That’s just the way it is,” is unprofessional and uncaring. Saying, “I don’t know when the bowels will shut down, but they will eventually,” projects an uncaring attitude and does not address the wife’s concern for her husband or her need for information. Although it may be true that the pain medication will slow bowel function, this does not provide the wife with the information she is seeking. CN: Psychosocial adaptation; CL: Apply 115. 4. It is important to allow the client to choose his or her own form of spiritual support. The dying client who is weakened by disease may not be able to attend services. The client must be consulted before referral to a chaplain is made. Reflection on past accomplishments may be comforting to the client, but it does not directly address spiritual concerns. CN: Psychosocial adaptation; CL: Synthesize 116. 2. A social worker can provide information for supportive services and can help the client with financial concerns. A bank representative, loan officer, or someone from the hospital billing depart- ment may be needed; however, it is most appropri- ate for the social worker to first assess the client’s needs. CN: Psychosocial adaptation; CL: Synthesize 117. 4. Dehydration is an expected event within the dying process. Hydration may be used in any situation of dehydration as long as it is within the client and family’s wishes. Rehydrating the client may actually prolong the dying process. Decisions about treatment are made with the CN: Basic care and comfort; CL: Apply 71 118. 4. The nurse must first allow the client to explore his or her own beliefs and values before making referrals, explaining various religious beliefs, or suggesting appropriate reading material. CN: Psychosocial adaptation; CL: Synthesize 119. 3. The family is in the best position to give the information they elect to disclose to friends and community members. The hospice nurse and the oncologist must maintain client confidential- ity and follow HIPPA guidlelines for release of confidential information. Therefore, disclosing any information about the client’s condition would be inappropriate. CN: Management of care; CL: Synthesize 120. 4. Depression can be a mixture of affective responses (feelings of worthlessness, hopelessness, sadness), behavioral responses (appetite changes, withdrawal, sleep disturbances, lethargy), and cognitive responses (decreased ability to concen- trate, indecisiveness, suicidal ideation). Increased decisiveness, problem-solving ability, and increased social interactions are reflective of adaptive coping. CN: Psychosocial adaptation; CL: Analyze 121. 4. Bereavement support after death usually continues for about 1 year or as needed at little or no cost to the remaining family. Mutual sup- port groups by nonprofessionals are usually free or inexpensive but are not necessarily appropriate for young children. Professional individual counseling and medication are expensive, and medication may not be appropriate for young children. To remind someone of what she should have done before the death is not helpful at this time. CN: Psychosocial adaptation; CL: Synthesize 122. 3. It is important to establish rapport with the client and family by listening to verbal and nonverbal concern and showing respect for cul- tural differences. The use of touch or eye contact is culture-specific and cannot be generalized as an intervention for all individuals with cancer. Mis- communication between individuals of different cultures is often caused by language differences, rules of communication, age, and gender. CN: Psychosocial adaptation; CL: Synthesize 123. 1. Helping the client to identify available resources allows the client respect and time to make informed decisions and encourages him to become actively involved with treatment options. Encouraging compliance with treatment regimens 72 discourages the client from becoming actively involved in his treatment and diminishes coping ability. Relieving the client of decision making as much as possible is not appropriate and encour- ages feelings of helplessness and powerlessness. Assisting the client to prepare for adverse treatment effects may foster hopelessness and increase anxiety by focusing on adverse outcomes too soon. CN: Psychosocial adaptation; CL: Synthesize 124. 4. These American Cancer Society– sponsored groups are designed to educate clients and their families experiencing cancer about the disease and methods of coping positively with it. These are self- help and support groups monitored by professionals and cancer survivors who have undergone a training course that helps them to facilitate small groups. CN: Psychosocial adaptation; CL: Apply 125. 4. Many cancer survivors question why they are doing so well and others are not. Often they express feeling guilty when they hear that oth- ers are not doing well. Suggesting that the client does not know how to describe his own emotions is inappropriate and may discourage him from expressing his feelings. Although the client may be experiencing volatile emotions, this is not the likely source of his feelings of guilt. Guilt about doing well after cancer treatment is not a spiritual response to illness. CN: Psychosocial adaptation; CL: Synthesize 126. 4. The recurrence of the disease is found to be the most distressing time, and clients may experi- ence anxiety, depression, and suicidal ideation. Cli- ents may feel a decrease in their anxiety and depres- sion with the initiation of definitive treatment or at the end of their first course of treatment. Clients in the end stage of the disease may feel all of these emotions; however, when clients have been free from cancer for some time and learn that there is a recurrence, they often experience a sharp increase in their feelings of distress. CN: Psychosocial adaptation; CL: Analyze 127. 2. Powerlessness is a subjective experience of helplessness and apathy that can be threatening to one’s competency and result in increased depen- dence on others. Effective nursing interventions will provide opportunities for the client to be involved in decision making and to regain a sense of control. Ineffective coping may also be a response to altered mobility, but the nursing interventions would be directed toward enhancing coping skills. Impaired adjustment is characterized by statements or actions 75 and validates the client’s feelings. Psychiatric 76 636 The Nursing Care of Adults with Medical and Surgical Health Problems help and antidepressant medication may be options if the depression is severe and prolonged. Encour- aging a client to see the good or positive side of a situation minimizes the client’s feelings. CN: Psychosocial adaptation; CL: Synthesize 132. 2. Individuals who are experiencing fatigue need to prioritize their activities and ask for assis- tance from others. It is best not to take away all of the client’s activities because her role as wife and mother is obviously important to her and to her sense of self-worth. Suggesting that she ignore the household chores or telling her not to worry because everyone gets tired disregards the client’s feelings and is not appropriate. CN: Basic care and comfort; CL: Synthesize 133. 4. Tachycardia, tachypnea, moist or clammy skin, and disorientation are classic symptoms of delirium. Clients with panic disorder do not exhibit disorientation. Clients with depression exhibit a flat affect, apathy, and sleep disturbances. Clients with schizophrenia have thought disorders such as hal- lucinations or delusions. CN: Physiological adaptation; CL: Analyze 134. 2. A progressive activity regimen may be prescribed to increase pulmonary function after sur- gical lung resection. Rehabilitation should include walking and some stair climbing as tolerated. Vigor- ous exercise is usually not recommended initially. Joining the Lost Chord Club and learning tracheo- stomy care are appropriate for the client who has undergone a laryngectomy. CN: Psychosocial adaptation; CL: Synthesize 135. 4. Serving as a volunteer in a client-to-client program represents reintegration with constructive channeling of energies, which indicates a higher level of adaptation than attention to safety, knowl- edge, or planned activity. CN: Psychosocial adaptation; CL: Evaluate The Client Who Is Experiencing Problems with Sexuality 136. 3. Water-soluble lubricants used during sexual intercourse can augment reduced natural vagin*l lubrication caused by ovarian dysfunction and decreased circulating estrogen related to che- motherapy. The use of vagin*l dilators, relaxation techniques, or nightly douches would not increase 77 vagin*l lubrication. Frequent douching can disrupt the normal vagin*l environment. CN: Health promotion and maintenance; CL: Synthesize 137. 3. Placing a thin piece of gauze over the tracheostomy during sexual activity will help to contain the secretions and yet allow ventilation. Although a scopolamine patch may depress the salivary and bronchial secretions, it is not recom- mended for long-term use and would not be indi- cated in this situation. Avoiding fluids before sexual activity is not recommended to decrease secretions. Washing the tracheostomy area with any deodor- izing soap may cause skin irritation and place the client at risk for CN: Health promotion and maintenance; CL: Synthesize 138. 4. This question introduces some basic infor- mation and allows for support for the client who may be experiencing some sexuality concerns. Not all women experience sexual problems after under- going a hysterectomy. Assuming that the client will want to schedule an appointment with her partner is inappropriate and may embarrass her. Simply ask- ing the client whether she expects to have problems with sex is too abrupt and does not provide any information. CN: Psychosocial adaptation; CL: Synthesize 139. 4. Although there may not be a big change in sexual function with a unilateral orchiectomy, the loss of a gonad and testosterone may result in decreased libido and sterility. Sperm banking may be an option worth exploring if the number and motility of the sperm are adequate. Remember, the population most affected by testicular cancer is gen- erally young men ages 15 to 34, and in this crucial stage of life, sexual anxieties may be a large CN: Psychosocial adaptation; CL: Synthesize 140. 4. The risk of becoming neutropenic during chemotherapy is very high. Therefore, an inserted foreign object such as a diaphragm may be a nidus for infection. Although the nurse may wish to inform the client about the ease with which various contraceptive modalities may be used, the focus of this discussion should be on preventing an infec- tion, which can be fatal for the neutropenic client. There are no data to suggest the client is at risk for acquiring a sexually transmitted disease. The client will not be experiencing body changes directly related to hormonal changes. CN: Safety and infection control; CL: Synthesize 80 The Client with Cancer 637 regard to making health care decisions and the use of advance directives. CN: Management of care; CL: Apply 146. 3. The goal of client autonomy is to respect the client’s choice not to know particular informa- tion. The client’s best interests should be deter- mined by the client after he or she receives all the necessary information and in conjunction with other people of the client’s choice, including family, physicians, and other health care personnel. The client’s best interests are not totally directed by the physician or the health care team. CN: Management of care; CL: Evaluate End-of-Life Care 147. 1, 2, 5. In 1991, the Omnibus Reconciliation Act became effective. This Patient Self-Determina- tion Act requires all institutions that participate in Medicare to provide information about and the right to initiate advance directives. Advance directives are written statements of person’s wishes related to health care if they are unable to decide for them- selves. These documents relate to current or future health care and not past medical history. Competent adults are responsible for their own health care decisions and their own right to accept or refuse treatment. Advance directives are used when the person cannot make the decision. Medical power- of- attorney is a term used to describe the person who makes health care decisions should someone be unable to make informed decisions for himself or herself. The focus is not primarily financial access. CN: Management of care; CL: Evaluate 148. 4. The advocacy role of the nurse implies that the nurse will ensure that the client’s wishes are being respected and that she is making informed decisions. Therefore, the nurse will assist in ensur- ing that the client is fully informed. The other interventions are appropriate for the nurse but are not related to client advocacy. The client may not understand or have all the necessary information for standard therapy. A client who is taking an alterna- tive therapy should be monitored for adverse effects. If a client is taking an alternative therapy, it is essen- tial 81 for the physician to know so that the therapy can be incorporated into the client’s treatment plan and to ensure that there are no incompatibilities with other therapies or medications. CN: Management of care; CL: Evaluate 149. 2, 3, 4, 5. End-of-life care is the term currently used for issues related to death and dying. End-of- life care focuses on physical and psychosocial needs at the end of life for the client and client’s family. 82 638 The Nursing Care of Adults with Medical and Surgical Health Problems Palliative care is health care aimed at symptom management rather than curative treatment for dis- eases. Goals would include providing comfort and support for the client and family and improving the client’s quality of life. Grief counseling is a compo- nent and efforts would be to enhance the coping of all involved and not to alter usual coping methods. CN: Management of care; CL: Create 150. 3. The best nursing advocacy intervention is listening carefully to the client’s and family’s per- ceptions of their needs. Studies have demonstrated that these needs are not necessarily what the nurse thinks they are. Intervening without listening care- fully may result in a lack of responsiveness to the real needs. Helping the client and family maintain a sense of optimism and hopefulness is appropri- ate but is not necessarily advocacy. Determining the client’s and family’s understanding of the results of the diagnostic testing and providing written materials about the cancer site and its treatment are examples of the nurse’s role as educator. CN: Psychosocial adaptation; CL: Synthesize 151. 1. The nurse would give the client a tissue and tell him it’s okay to cry to convey acceptance and empathy. He needs to know that it is natural to have tremendous feelings of loss and sadness. Telling the client to stop crying, busying oneself in the client’s room, and changing the subject are not helpful to the client because they ignore his needs and inhibit the expression of emotion. CN: Psychosocial adaptation; CL: Synthesize 152. 2, 3, 4, 5, 6. With serious, chronic, and ter- minal illnesses, it is important to help clients and families address fears, difficulties with home care, advance directives, hospice and home care options, and final arrangements. Predicting the length of life for this client is not appropriate at CN: Psychosocial adaptation; CL: Synthesize 153. 1. The client’s husband is experiencing anger, much of which stems from feelings of guilt about not taking the trip. During the stage of denial, the husband is more likely to deny the client’s diagno- sis and prognosis. During the stage of bargaining, the husband would offer to do certain things in exchange for more time before the client dies. In the stage of depression, the husband is likely to make few or no comments and to act CN: Psychosocial adaptation; CL: Analyze 154. 1. When supporting the friends or family of a terminally ill client, it is best to focus on the 85 CN: Management of care; CL: Synthesize 162. 4. To determine the cause of this problem, a quality improvement study should be conducted. 86 The Client with Cancer 639 Before implementing solutions to a problem, the precise issues in the hospital system must be observed and documented. The Joint Commission requirements mandate documentation of the effec- tiveness of analgesia within 30 minutes after admin- istration. It is not the pharmacist’s role to provide consultation about documentation of drugs adminis- tered by nurses. Consulting the evening nurses may be helpful, but this is a systems issue of the entire unit and involves every registered nurse administer- ing analgesia. CN: Management of care; CL: Create 163. 2. The RN is responsible for describing to the UAP when to report to the RN a result that indicates a potential client problem with dehydration. The RN must assess and interpret results, but must give con- crete feedback to the UAP on what is an expected situation or a specific result to report back to the RN. Urine output should be at least 30 mL/hour, or 240 mL over the 8-hour shift. Dehydrated clients may be thirsty and the UAP can ask if the client is thirsty and offer water if permitted. However, because urine output is the critical indicator of dehydration, the UAP should document I&O and give results outside the normal range to the nurse. The nurse is specifi- cally assessing dehydration and should request to receive this information. CN: Management of care; CL: Synthesize 164. 4. A bedside commode should be near the client for easy, safe access. Measurement of urine output is also important in a client with heart failure. Putting diapers on an alert and oriented individual would be demeaning and inappropriate. Indwelling catheters are associated with increased risk of infection and are not a solution to possible incontinence. There is no reason to think that the client would not be able to use the bedside com- mode. CN: Safety and infection control; CL: Synthesize 165. 1. Ongoing assessment by the RN is required to evaluate the client with dyspnea to monitor for potential deterioration of the respiratory status. If the RN is the care provider, she will have greater interaction with the individual client. The RN is responsible for assessment of all the clients. The other clients would not be considered unstable, and maintaining a patent airway is always the priority in providing care. Care for the other clients could be 87 assigned safely, according to the abilities of the LVN- LPN and UAP. CN: Management of care; CL: Synthesize