Chapter 21, 22, 40, 43, and 45 Critical Critical Judgement Questions and Examination Challenges Flashcards
p. 365, Physiological Integrity
Which pathologic description of a client’s tumor does the nurse interpret as being the “most malignant” or “high grade” cancer?
A. Poorly differentiated; mitotic index = 20%, euploid
B. Moderately differentiated; mitotic index = 50%, euploid
C. Undifferentiated; mitotic index = 50%, aneuploid
D. Highly differentiated; mitotic index = 10%, aneuploid
Answer: C
Rationale: Tumors that closely resemble normal cells are “less malignant,” and those that have few normal cell features are “more malignant.” Thus, those that are euploid are less malignant and those that are aneuploid, with abnormal numbers or structures of chromosomes, are more malignant. Less malignant cells are highly differentiated, and more malignant cells are poorly or undifferentiated. Cells that divide faster (have a higher mitotic index) are more malignant.
p. 369, Health Promotion and Maintenance
A 65-year-old client tells the nurse she does not have mammograms because there is no history of breast cancer in her family. What is the nurse’s best response?
A. “You are correct. Breast cancer is an inherited type of malignancy and your family history indicates a low risk for you.”
B. “Performing breast self-examination monthly at home is sufficient screening for someone with your family history.”
C. “Because your breasts are no longer as dense as they were when you were younger, your risk for breast cancer is now decreased.”
D. “Breast cancer can be found more frequently in families; however, the risk for general, nonfamilial breast cancer increases with age.”
Answer: D
Rationale: Only a small percentage of cancers, including breast cancers, are hereditary or familial. The far more critically important risk factor for breast cancer in women is advancing age. Although performance of monthly self-breast examination is good, for a woman of this age, it should be done in conjunction with a yearly mammogram.
p. 377, Psychosocial Integrity
The client receiving brachytherapy with implanted radioactive “seeds” for prostate cancer asks the nurse when these seeds will be removed. What is the nurse’s best response?
A. “The half-life of radiation in these seeds is so short that it is not necessary to remove them.”
B. “They will only be removed if their presence is painful or leads to an enlarged prostate gland.”
C. “When we know for certain that all cancerous cells have been killed, the seeds will be removed.”
D. “The seeds are small enough to be absorbed by your body and excreted in the urine or stool.”
Answer: A
Rationale: The seeds are small and painless. The half-life of the radiation source is less than 2 weeks. Thus, it is not necessary for the seeds to be removed because they pose no health hazard to the client or anyone else. They are neither absorbed nor excreted by the body.
p. 383, Physiological Integrity
The client receiving high-dose chemotherapy who has neutropenia asks the nurse whether he and his wife can have sexual intercourse while he is receiving chemotherapy. What is the nurse’s best response?
A. “No, this activity will increase the side effects of the chemotherapy.”
B. “No, the danger of impregnating your wife is too great.”
C. “Yes, as long as you feel like it and use a condom.”
D. “Yes, if you do not have an infection.”
Answer: C
Rationale: Many people do not feel well enough to have sexual intercourse during the months they are taking chemotherapy. This activity is fine as long as the client takes precautions to limit chemotherapy drug exposure to his partner and protects himself from infection and trauma. Wearing a condom reduces chemotherapy drug exposure to his partner (as a result of any drugs entering the seminal fluid or are in the urethra from presence in the urine) and reduces his risk for developing an ascending urinary tract infection.
p. 387, Health Promotion and Maintenance
Which precaution is most important for the nurse to teach the client who has chemotherapy-induced peripheral neuropathy?
A. Avoid taking aspirin or any aspirin-containing products.
B. Use a bath thermometer to check bath water temperature.
C. Do not use mouthwashes that contain alcohol or glycerin.
D. Bathe daily using an antimicrobial soap or gel.
Answer: B
Rationale: Peripheral neuropathy reduces the ability to discriminate temperature sensation. It is very easy for a person with neuropathy to be unaware of water temperature and to become injured as a result of water for bathing or showering being too hot. Aspirin, although important to avoid when platelets are low, is not contraindicated with peripheral neuropathy. Alcohol or glycerin mouthwashes are contraindicated for mucositis, not peripheral neuropathy. Bathing with an antimicrobial soap helps prevent infection but does not prevent injury.
p. 394, Safe and Effective Care Environment
Which change in health status indicates to the nurse that the client’s superior vena cava syndrome is worsening?
A. The client’s systolic blood pressure is rising, and the diastolic pressure is decreasing.
B. The client’s severe nausea and vomiting no longer responds to antiemetics.
C. The client has experienced four nose bleeds in the past 2 days.
D. Pedal edema is now present.
Answer: C
Rationale: With superior vena cava syndrome, blood flow through the vena cava is compromised as a result of tumor growth. As blood backs up in the venous system drained by the superior vena cave, pressure in the veins increases and nose bleeds (epistaxis) occur easily and more frequently. The increased venous pressure would not increase systolic pressure. Response to antiemetics is not affected by superior vena cava syndrome. Pedal edema could occur in response to a blockage in the inferior vena cava but not the superior vena cava.
p. 374, Ethical/Legal
Mrs. W. is an 80-year-old woman who has undergone exploratory surgery for an acute bowel obstruction. She had been relatively healthy, although growing more frail in recent years, and recently began to need home oxygen intermittently for chronic lung disease. Persistent abdominal pain and vomiting brought her to the emergency department. She lives alone, in an assisted living apartment, near her daughter Joan, who provides some additional assistance with grocery shopping, bill paying, etc. Mrs. W. has just been admitted to the ICU after surgery, where she is expected to remain intubated and mechanically ventilated overnight. The surgeon and Mrs. W’s daughter are talking outside of her room. You join the conversation in time to hear the surgeon explain that a large, disseminated cancer was found as the cause of the obstruction; he removed as much as he could but was not able to resect all of the cancer. Joan responds, “I was afraid of this. Whatever you do, don’t tell my mother it was cancer —she’ll never be able to cope with that. Please, just tell her that it was a benign tumor and you took it out.” The surgeon looks uncertain but nods and then leaves the bedside. Joan turns to you and says, “Tell the other nurses—nobody can say it was cancer.”
- What, if anything, should you say to Joan at this point?
It is now the next day. As expected, Mrs. W. has remained stable through the night and has been successfully extubated. She is still somewhat sleepy and has not asked any questions about her surgery. When Joan comes in to visit, she pulls you aside and says, “No one told her about the cancer, right?”
- How should you respond to Joan now?
- Review the ethical principles in chapter 1. What ethical principle(s) are at risk or in play with this situation?
- What, if anything, should you say to Joan at this point?
The nurse in this situation would be aware of the stress Joan is under, both from the ongoing caregiving responsibilities she bears and the news of her mother’s cancer. Because Mrs. W. is likely to be quite somnolent from the anesthesia and pain medicine and will not be able to talk until she is extubated in the morning, there is no need to resolve the issue of what to tell Mrs. W. at this moment. The nurse’s best response would be to reassure Joan that there will be time tomorrow to talk about what to tell her mother, that Mrs. W. will be sleepy through the night and the focus of her care will be to keep her comfortable, monitor vital signs, and evaluate her respiratory status. The nurse should also begin discussions with the rest of the care team, including the surgeon and other nursing staff, to form a plan for what to tell Mrs. W. and her daughter in the morning. - How should you respond to Joan now?
It is becoming more likely that Mrs. W. might, as she becomes more awake, ask questions about her condition. You cannot intentionally deceive Mrs. W by giving her false information, but you are also obligated to address duties to be truthful without imposing avoidable harm on both Mrs. W and her daughter. Joan is still anxious about how her mother will cope with the information about her diagnosis. First, assure Joan that no one has discussed the diagnosis. Then gently explain that it would not be acceptable to lie to her mother if she directly asks about her diagnosis but that the treatment team (doctors and nurses) will work with Joan to develop a plan for how and when to discuss Mrs. W.’s condition with Joan and her mother. - What ethical principle(s) are at risk or in play with this situation?
The principle of veracity (truth telling) imposes a relatively absolute duty on you as the nurse to refrain from intentionally deceiving patients. However, because you also have duties of nonmaleficence (avoid harm), you must avoid simply revealing blunt truth without attention to the consequences. This often requires very careful and early anticipatory planning so that patients can be provided with truthful information in a considerate and caring environment, with support persons in attendance. In addition, you also have duties to the patient’s family member to avoid increasing their distress. Ignoring their concerns and being insensitive to their needs would definitely increase their stress unnecessarily.
p. 801, Safe and Effective Care Environment
Which new assessment finding in a client with sickle cell disease who currently is in crises does the nurse report immediately to the health care provider?
A. Pain in the right hip with limited range of motion
B. Slow capillary refill in the toes of the right foot
C. Yellow appearance of the roof of the mouth
D. Facial drooping on the right side
Answer: D
Rationale: All current assessment findings are important. However, the pain in the hip, the slow capillary refill, and the yellow appearance of the roof of the mouth are related to the crises and are expected. The facial drooping as a new finding indicates the possibility of reduced brain perfusion and stroke. This dew development requires immediate attention and intervention.
p. 806, Health Promotion and Maintenance
Which intervention is most important for the nurse to teach the client with polycythemia vera to prevent injury as a result of the increased bleeding tendency?
A. Use a soft-bristled toothbrush.
B. Drink at least 3 liters of liquids per day.
C. Wear gloves and socks outdoors in cool weather.
D. Exercise slowly and only on the advice of your physician.
Answer: A
Rationale: The other interventions focus on preventing venous stasis, clot formation, and myocardial infarction. Using a soft-bristled toothbrush minimizes trauma to the gums and prevents bleeding.
p. 809, Physiological Integrity
The blood of a client who has chronic myelogenous leukemia shows a high percentage of blast cells and promyelocytes. What is the nurse’s correct interpretation of this test result?
A. The client’s risk for infection is decreasing.
B. The disease has become more aggressive.
C. The drug therapy for the disease is effective.
D. The type of leukemia is now lymphocytic rather than myelogenous.
Answer: B
Rationale: The leukemia is progressing and the drug therapy is no longer effective. CML has three phases: The chronic phase is often a slowly progressing (indolent) course during which the patient may have mild symptoms and respond to standard treatments. The bone marrow usually shows less than 10% blast cells at this time. The accelerated phase features spleen enlargement and progressive manifestation, such as intermittent fevers, night sweats, and unexplained weight loss. The patient usually does not respond to standard treatment, and the bone marrow may contain 10% to 30% blast cells and promyelocytes. The blast phase indicates transformation to a very aggressive acute leukemia. The bone marrow contains more than 30% blast cells. The promyelocytes and blast cells commonly spread to other tissues and organs. The leukemia becomes more similar to acute leukemia than chronic leukemia but does not change from myelogenous to lymphocytic. With so many blast cells that are immature and do not function properly, the client is now at greatly increased risk for infection.
p. 814, Safe and Effective Care Environment
The client is 3 weeks post-transplant from an allogeneic stem cell transplantation for acute lymphocytic leukemia. There is now some peeling of the client’s skin on the palms of the hands and the soles of the feet. Which additional assessment data supports the nurse’s suspicion of possible graft-versus-host disease (GVHD)?
A. The client’s temperature is slightly below normal.
B. Today’s platelet count is 5,000/mm3 and the WBCs are low.
C. The client has had 6 to 10 watery stools daily for 3 days.
D. The client’s urine output is less than 800 mL in 24 hours.
Answer: C
Rationale: GVHD occurs when the immunocompetent cells of the donated marrow recognize the patient’s (recipient) cells, tissues, and organs as foreign and start an immunologic attack against them. The tissues most susceptible are the skin, intestinal tract, and liver. The earliest manifestation of gastrointestinal involvement for GVHD is large-volume watery diarrhea. The temperature is unaffected. The fact that the urine output is low is related to dehydration from diarrhea, not kidney damage by GVHD.
p. 826, Safe and Effective Care Environment
The nurse who just came on duty observes that the client, whose blood type is AB negative, is receiving a transfusion with type O negative packed red blood cells. What is the nurse’s best first action?
A. Call the blood bank.
B. Take and record the client’s vital signs.
C. Stop the transfusion and keep the IV open.
D. Document the observation as the only action.
Answer: B
Rationale: Clients with AB negative blood types can receive O negative blood because they do not have antibodies against this type of blood. Therefore, the transfusion does not need to be stopped nor does the blood bank need to be notified. The transfusion can proceed. Because the nurse is seeing the client for the first time since the transfusion was initiated, the client’s vital signs need to be assessed rather than just documenting the observation.
p. 802, Ethical/Legal
A 27-year-old African-American man in sickle cell crisis is a patient on your unit. During report, one of the nurses from the previous shift mentions that she withheld the regularly scheduled IV opioid pain medication during the night because she had taken care of this patient a year ago and believes that he is a “drug seeker.”
1. What is your first action?
2. How should you approach your colleague?
3. Can a patient with sickle cell disease become addicted to opioids?
4. What can you do to prevent an incident like this one from happening again?
Suggested responses:
- What is your first action?
Stop report and go and assess the patient for pain and administer the prescribed scheduled opioid. The pain during crisis is intense. Pain medication, including opioids, must be given on a scheduled basis and not as needed, and they should not be withheld. - How should you approach your colleague?
After you have seen to your patient’s comfort, remind her that unless there is a physiologic danger, such as severe respiratory depression, she is legally required to administer the prescribed opioid regardless of her beliefs. Determine whether she assessed the patient for pain and what, for this episode, not the patient’s behavior a year ago, convinced her that the pain is not real. - Can a patient with sickle cell disease become addicted to opioids?
It is possible for any patient with chronic pain that may have acute exacerbations to become addicted to opioids. However, this should never be assumed. Even if addiction did occur, the pain is real and must be appropriately managed, including the use of opioid analgesics. - What can you do to prevent an incident like this one from happening again?
Speak to the nurse manager and the patient’s health care provider about the incident. It is likely that this nurse does not understand the pathophysiology of sickle cell crisis or its management. There may be other nurses who have similar views. Arrange for a sickle cell disease and pain specialist to hold mandatory inservices on this topic for the entire staff on this unit.
p. 813, Safety; Teamwork and Collaboration The patient is a 44-year-old chemical plant foreman who developed acute myelogenous leukemia 6 months ago. His initial therapy was successful, and he is scheduled to have a stem cell transplant (bone marrow) with his identical twin brother as the donor. His brother lives in the same city and is a professor at a local university. The patient is very grateful that his brother will donate bone marrow and states that he is certain that he has no risk for infection during the procedure because his brother is his identical twin. 1. What type of class of stem cell transplant would this procedure be considered? 2. Is the patient correct in assuming that he has no risk for infection because the donor is his twin brother? Provide a rationale for your response. 3. Which, if any, complications of stem cell transplantation are reduced or eliminated by having an identical sibling donate the stem cells? 4. Which, if any, complications (and why) are still possible even with a donor who is an identical sibling?
Suggested responses:
1. What type of class of stem cell transplant would this procedure be considered? When the donor is an identical sibling, all major and minor tissue antigens are a perfect match, not just the six standard major ones. Therefore, this is considered a syngeneic transplant.
- Is the patient correct in assuming that he has no risk for infection because the donor is his twin brother? Provide a rationale for your response.
No, the patient is not correct. The patient will still have to undergo a conditioning regimen to clear his own, potentially leukemic, cells. Thus he will still be profoundly immunosuppressed and at great risk for infection unless and until his brother’s stem cells properly engraft and grow in his body. - Which, if any, complications of stem cell transplantation are reduced or eliminated by having an identical sibling donate the stem cells?
The risk for GVHD is greatly reduced, although not completely eliminated, because the transplanted stem cells are identical to his own cells. The risk for veno-occlusive disease is likewise greatly reduced. - Which, if any, complications (and why) are still possible even with a donor who is an identical sibling?
In addition to infection, other pancytopenia problems can occur until full engraftment. The patient will be at risk for bleeding complications and may need both red blood cell and platelet transfusions after transplantation. It is possible that engraftment may not occur for many reasons, the most common of which is insufficient stem cells transplanted. Although HSCT can help cure leukemia, it is still possible that not all cancerous bone marrow cells were killed and could come back.
p. 818, Prioritization, Delegation, and Supervision
The patient is a 52-year-old woman who has undergone an autologous stem cell transplantation for non-Hodgkin’s lymphoma. She is recovering, and her white blood cell count is improving but still very low. She remains on neutropenic precautions. The LPN reports that the patient’s heart rate, respiratory rate, temperature, and blood pressure are all elevated.
1. Which vital sign finding would you report to the health care provider immediately and why?
2. You must assign an unlicensed assistive personnel (UAP) to help care for this patient. Of the four UAPs available, one is newly pregnant and has worked on this unit for 3 years, one has had cold symptoms for 3 days, one has not yet cared for a patient on neutropenic precautions, and one has a fear of people with cancer. Which UAP should you avoid assigning to this patient? Provide a rationale for your choice.
3. A nursing student tearfully reports to you, “I took some flowers into the patient’s room to cheer him up and he told me that he didn’t think he was supposed to have flowers. I took them out of the room right away and then I realized I had made a mistake.” How should you respond to this student?
4. The student asks you whether a book still wrapped in shrink wrap just now brought in by a friend of the patient can be taken to the patient’s room. How will you help the student know what to do in this situation?
Suggested responses:
- Which vital sign finding would you report to the health care provider immediately and why?
The temperature elevation, no matter how slight, in a patient with neutropenia indicates infection until it has been ruled out. This elevation should be reported immediately, and you need to take the standard neutropenic interventions of full assessment, obtaining appropriate specimens for culture, obtaining chest radiography, and starting antibiotic therapy. - You must assign an unlicensed assistive personnel (UAP) to help care for this patient. Of the
four UAPs available, one is newly pregnant and has worked on this unit for 3 years, one has had cold symptoms for 3 days, one has not yet cared for a patient on neutropenic precautions, and one has a fear of people with cancer. Which UAP should you avoid assigning to this patient? Provide a rationale for your choice.
Assign the UAP who is newly pregnant and very experienced to assist with this patient. The patient’s possible infection is not harmful to the pregnant UAP because the infection is most likely from overgrowth of the patient’s normal flora. Infection in a patient with neutropenia can lead to sepsis and death very quickly. Therefore, an experienced and healthy caregiver is critical. The UAP who fears people with cancer may let his or her fear overshadow the ability to provide appropriate care. If this person fears cancer, he or she may also fear infection. In fact, it may be appropriate to request that this UAP be transferred to a unit that does not include people with cancer in its usual population. - A nursing student tearfully reports to you, “I took some flowers into the patient’s room to
cheer him up, and he told me that he didn’t think he was supposed to have flowers. I took them out of the room right away, and then I realized I had made a mistake.” How should you respond to this student?
Acknowledge the student for taking responsibility for the error. Helping the student to feel comfortable in reporting errors rather than hiding mistakes is essential for patient safety. Then go with the student to explain the situation to the nursing instructor so that the student can be counseled and procedures reviewed. Suggest to the instructor that the incident be used as a “teachable moment” and carefully shared with the other students. Suggest that the students discuss some of the ways patients with neutropenia can be protected from infections during hospitalization. - The student asks you whether a book still wrapped in shrink wrap just now brought in by a
friend of the patient can be taken to the patient’s room. How will you help the student know what to do in this situation?
A book in shrink wrap could have potential organisms on it. However, the shrink wrap is waterproof. Tell the student to cleanse the shrink wrap with an alcohol-based hand rub and then remove the shrink wrap before giving the book to the patient. Although the book and its jacket are not sterile, they most likely have been handled only by machines in the printing process and are unlikely to convey pathogenic microorganisms (or any other organisms) to the patient.
