Exam 2 Flashcards
A 73-year-old male patient admitted for total knee replacement states during the health history interview that he has no problems with urinary elimination except that the “stream is less than it used to be.” The nurse should give the patient anticipatory guidance that what condition may be developing?
A. A tumor of the prostate
B. Benign prostatic hyperplasia
C. Bladder atony because of age
D. Age-related altered innervation of the bladder
B. Benign prostatic hyperplasia
Benign prostatic hyperplasia is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men over age 50 and 80% of men over age 80. Only about 16% of men develop prostate cancer. Bladder atony and age-related altered innervations of the bladder do not lead to a weakened stream.
To accurately monitor progression of a symptom of decreased urinary stream, the nurse should encourage the patient to have which primary screening measure done on a regular basis?
A. Uroflowmetry
B. Transrectal ultrasound
C. Digital rectal examination (DRE)
D. Prostate-specific antigen (PSA) monitoring
C. Digital rectal examination (DRE)
Digital rectal examination is part of a regular physical examination and is a primary means of assessing symptoms of decreased urinary stream, which is often caused by benign prostatic hyperplasia in men over 50 years of age. The uroflowmetry helps determine the extent of urethral blockage and the type of treatment needed but is not done on a regular basis. Transrectal ultrasound is indicated with an abnormal DRE and elevated PSA to differentiate between BPH and prostate cancer. The PSA monitoring is done to rule out prostate cancer, although levels may be slightly elevated in patients with BPH.
The patient has had cardiovascular disease for some time and has now developed erectile dysfunction. He is frustrated because he cannot take erectogenic medications because he takes nitrates for his cardiac disease. What should the nurse do first to help this patient?
A. Give the patient choices for penile implant surgery.
B. Recommend counseling for the patient and his partner.
C. Obtain a thorough sexual, health, and psychosocial history.
D. Assess levels of testosterone, prolactin, LH, and thyroid hormones.
C. Obtain a thorough sexual, health, and psychosocial history.
The nurse’s first action to help this patient is to obtain a thorough sexual, health, and psychosocial history. Alternative treatments for the cardiac disease would then be explored if that had not already been done. Further examination or diagnostic testing would be based on the history and physical assessment, including hormone levels, counseling, or penile implant options.
After a vasectomy, what teaching should be included in the discharge teaching?
A. “You will want to use an alternative form of contraception for 6 weeks.”
B. “You may lose some secondary sexual characteristics after this surgery.”
C. “You may have erectile dysfunction for several months after this surgery.”
D. “You will be uncomfortable, but you may safely have sexual intercourse today.”
A. “You will want to use an alternative form of contraception for 6 weeks.”
As vasectomies are usually done for sterilization purposes, to safely have sexual intercourse, the patient will need to use an alternative form of contraception until semen examination reveals no sperm, usually at least 10 ejaculations or 6 weeks to evacuate sperm distal to the surgical site. Hormones are not affected, so there is no loss of secondary sexual characteristics or erectile function. Most men experience too much pain to have sexual intercourse on the day of their surgery, so this is not an appropriate comment by the nurse.
A male patient complains of fever, dysuria, and cloudy urine. What additional information may indicate that these manifestations may be something other than a urinary tract infection (UTI)?
A. E. coli bacteria in his urine
B. A very tender prostate gland
C. Complaints of chills and rectal pain
D. Complaints of urgency and frequency
B. A very tender prostate gland
A tender and swollen prostate is indicative of prostatis, which is a more serious male reproductive problem because an acute episode can result in chronic prostatis and lead to epididymitis or cystitis. E. coli in his urine, chills and rectal pain, and urgency and frequency are all present with a UTI and not specifically indicative of prostatis.
A 33-year-old patient noticed a painless lump in his scrotum on self-examination of his testicles and a feeling of heaviness. The nurse should first teach him about what diagnostic test?
A. Ultrasound
B. Cremasteric reflex
C. Doppler ultrasound
D. Transillumination with a flashlight
A. Ultrasound
When the scrotum has a painless lump, scrotal swelling, and a feeling of heaviness, testicular cancer is suspected, and an ultrasound of the testes is indicated. Blood tests will also be done. The cremasteric reflex and Doppler ultrasound are done to diagnose testicular torsion. Transillumination with a flashlight is done to diagnose a hydrocele.
The patient has a low-grade carcinoma on the left lateral aspect of the prostate gland and has been on “watchful waiting” status for 5 years. Six months ago his last prostate-specific antigen (PSA) level was 5 ng/mL. Which manifestations now indicate that the prostate cancer may be growing and he needs a change in his care (select all that apply)?
A. Casts in his urine B. Presence of α-fetoprotein C. Serum PSA level 10 ng/mL D. Onset of erectile dysfunction E. Nodularity of the prostate gland
C. Serum PSA level 10 ng/mL Correct
E. Nodularity of the prostate gland Correct
The manifestations of increased PSA level along with the new nodularity of the prostate gland potentially indicate that the tumor may be growing. Casts in the urine, presence of α-fetoprotein, and new onset of erectile dysfunction do not indicate prostate cancer growth.
Which task can the nurse delegate to an unlicensed assistive personnel (UAP) in the care of a patient who has recently undergone prostatectomy?
A. Assessing the patient’s incision
B. Irrigating the patient’s Foley catheter
C. Assessing the patient’s pain and selecting analgesia
D. Performing cleansing of the meatus and perineal region
D. Performing cleansing of the meatus and perineal region
Performing perineal care is an appropriate task for delegation. Selecting analgesia, irrigating the patient’s catheter, and assessing his incision are not appropriate skills or tasks for unlicensed personnel.
A 71-year-old patient with a diagnosis of benign prostatic hyperplasia (BPH) has been scheduled for a contact laser technique. What is the primary goal of this intervention?
A. Resumption of normal urinary drainage Correct
B. Maintenance of normal sexual functioning
C. Prevention of acute or chronic renal failure Incorrect
D. Prevention of fluid and electrolyte imbalances
A. Resumption of normal urinary drainage
The most significant signs and symptoms of BPH relate to the disruption of normal urinary drainage and consequent urine retention, incontinence, and pain. A laser technique vaporizes prostate tissue and cauterizes blood vessels and is used as an effective alternative to a TURP to resolve these problems. Fluid imbalances, sexual functioning, and kidney disease may result from uncontrolled BPH, but the central focus remains urinary drainage.
A patient is one day postoperative following a transurethral resection of the prostate (TURP). Which event is not an expected normal finding in the care of this patient?
A. The patient requires two tablets of Tylenol #3 during the night.
B. The patient complains of fatigue and claims to have minimal appetite.
C. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased.
D. The patient has expressed anxiety about his planned discharge home the following day.
C. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased.
A decrease or cessation of output in a patient with CBI requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the patient or irrigating the catheter. Complaints of pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the patient’s CBI.
A 72-year-old male is in the emergency
department because he has been unable to void for
the past 12 hours. The best method for the nurse to
use when assessing for bladder distention in a male
client is to check for:
■ 1. A rounded swelling above the pubis.
■ 2. Dullness in the lower left quadrant.
■ 3. Rebound tenderness below the symphysis.
■ 4. Urine discharge from the urethral meatus.
.
- The best way to assess for a distended bladder in either a male or female client is to check for a rounded swelling above the pubis. This swelling represents the distended bladder rising above the pubis into the abdominal cavity. Dullness does not indicate a distended bladder. The client might experience tenderness or pressure above the symphysis. No urine discharge is expected; the urine flow is blocked by the enlarged prostate.
During a client’s urinary bladder catheterization,
the nurse ensures that the bladder is emptied
gradually. The best rationale for the nurse’s action is
that completely emptying an overdistended bladder
at one time tends to cause:
■ 1. Renal failure.
■ 2. Abdominal cramping.
■ 3. Possible shock.
■ 4. Atrophy of bladder musculature.
- Rapid emptying of an overdistended bladder may cause hypotension and shock due to the sudden change of pressure within the abdominal viscera. Previously, removing no more than 1000 mL at one time was the standard of practice, but this is no longer thought to be necessary as long as the overdistended bladder is emptied slowly.
The primary reason for lubricating the urinary
catheter generously before inserting it into a
male client is that this technique helps reduce:
■ 1. Spasms at the orifi ce of the bladder.
■ 2. Friction along the urethra when the catheter
is being inserted.
■ 3. The number of organisms gaining entrance to
the bladder.
■ 4. The formation of encrustations that may
occur at the end of the catheter.
- Liberal lubrication of the catheter before catheterization of a male reduces friction along the urethra and irritation and trauma to urethral tissues. Because the male urethra is tortuous, a liberal amount of lubication is advised to ease catheter passage. Lubrication of the catheter will not decrease spasms. The nurse should use sterile technique to prevent introducing organisms. Crusts will not form immediately. Irrigating the catheter as needed will prevent clot and crust formation.
The primary reason for taping an indwelling
catheter laterally to the thigh of a male client
is to:
■ 1. Eliminate pressure at the penoscrotal angle.
■ 2. Prevent the catheter from kinking in the urethra.
■ 3. Prevent accidental catheter removal.
■ 4. Allow the client to turn without kinking the
catheter.
- The primary reason for taping an indwelling catheter to a male client so that the penis is held in a lateral position is to prevent pressure at the penoscrotal angle. Prolonged pressure at the penoscrotal angle can cause a ureterocutaneous fistula.
Many older men with prostatic hypertrophy
do not seek medical attention until urinary obstruction
is almost complete. One reason for this delay in
seeking attention is that these men may:
■ 1. Feel too self-conscious to seek help when
reproductive organs are involved.
■ 2. Expect that it is normal to have to live
with some urinary problems as they grow
older.
■ 3. Fear that sexual indiscretions in earlier life
may be the cause of their problem.
■ 4. Have little discomfort in relation to the
amount of pathology because responses to
pain stimuli fade with age
- Research shows that older men tend to believe it is normal to live with some urinary problems. As a result these men often overlook symptoms and simply attribute them to aging. As part of preventative care for men older than 40, the yearly physical examination should include palpation of the prostate via rectal examination. Prostate specific antigen screening is also done annually to determine elevations or increasing trends in elevations. The nurse should teach male clients the value of early detection and adequate follow up for the prostate.
When caring for a client with a history of
benign prostatic hypertrophy (BPH), the nurse
should do which of the following? Select all that
apply.
■ 1. Provide privacy and time for the client to void.
■ 2. Monitor intake and output.
■ 3. Catheterize the client for post void residual
urine.
■ 4. Ask the client if he has urinary retention.
■ 5. Test the urine for hematuria.
1.2.4.5. Because of the history of benign prostatic hypertrophy, the nurse should provide privacy and time for the client to void. The nurse should also monitor intake and output, assess the client for urinary retention, and test the urine for hematuria. It is not necessary to catheterize the client.
The nurse should specifically assess a client
with prostatic hypertrophy for which of the following ?
■ 1. Voiding at less frequent intervals.
■ 2. Diffi culty starting the fl ow of urine.
■ 3. Painful urination.
■ 4. Increased force of the urine stream.
- Signs and symptoms of prostatic hypertrophy
include diffi culty starting the fl ow of urine, urinary
frequency and hesitancy, decreased force of the
urine stream, interruptions in the urine stream when
voiding, and nocturia. The prostate gland surrounds
the urethra, and these symptoms are all attributed
to obstruction of the urethra resulting from prostatic
hypertrophy. Nocturia from incomplete emptying
of the bladder is common. Straining and urine
retention are usually the symptoms that prompt the
client to seek care. Painful urination is generally not
a symptom of prostatic hypertrophy.
- The nurse is reviewing the medication history
of a client with benign prostatic hypertrophy
(BPH). Which medication will likely aggravate BPH?
■ 1. Metformin (Glucophage).
■ 2. Buspirone (BuSpar).
■ 3. Inhaled ipratropium (Atrovent).
■ 4. Ophthalmic timolol (Timoptic).
- Ipratropium is a bronchodilator, and its
anticholinergic effects can aggravate urine retention.
Metformin and buspirone do not affect the urinary
system; timolol does not have a systemic effect.
A client is scheduled to undergo transurethral
resection of the prostate. The procedure is to
be done under spinal anesthesia. Postoperatively,
the nurse should assess the client for:
■ 1. Seizures.
■ 2. Cardiac arrest.
■ 3. Renal shutdown.
■ 4. Respiratory paralysis.
- If paralysis of vasomotor nerves in the
upper spinal cord occurs when spinal anesthesia
is used, the client is likely to develop respiratory
paralysis. Artifi cial ventilation is required until the
effects of the anesthesia subside. Seizures, cardiac
arrest, and renal shutdown are not likely results of
spinal anesthesia.
A client with benign prostatic hypertrophy
(BPH) is being treated with terazosin (Hytrin) 2 mg
at bedtime. The nurse should monitor the client’s:
■ 1. Urine nitrites.
■ 2. White blood cell count.
■ 3. Blood pressure.
■ 4. Pulse.
- Terazosin is an antihypertensive drug that
is also used in the treatment of BPH. Blood pressure
must be monitored to ensure that the client does
not develop hypotension, syncope, or orthostatic
hypotension. The client should be instructed to
change positions slowly. Urine nitrates, white blood
cell count, and pulse rate are not affected by terazosin
A client underwent transurethral resection of
the prostate (TURP), and a large three-way indwelling
urinary catheter was inserted in the bladder
with continuous bladder irrigation. In which of the
following circumstances should the nurse increase
the flow rate of the continuous bladder irrigation?
■ 1. When drainage is continuous but slow.
■ 2. When drainage appears cloudy and dark yellow.
■ 3. When drainage becomes bright red.
■ 4. When there is no drainage of urine and irrigating
solution.
- The decision by the surgeon to insert a
catheter after TURP or prostatectomy depends on
the amount of bleeding that is expected after the
procedure. During continuous bladder irrigation
after a TURP or prostatectomy, the rate at which
the solution enters the bladder should be increased
when the drainage becomes brighter red. The color
indicates the presence of blood. Increasing the flow
of irrigating solution helps flush the catheter well so
that clots do not plug it. There would be no reason
to increase the fl ow rate when the return is continuous
or when the return appears cloudy and dark
yellow. Increasing the fl ow would be contraindicated
when there is no return of urine and irrigating
solution.
A client is to receive belladonna and opium
suppositories, as needed, postoperatively after
transurethral resection of the prostate (TURP). The
nurse should give the client these drugs when he
demonstrates signs of:
■ 1. A urinary tract infection.
■ 2. Urine retention.
■ 3. Frequent urination.
■ 4. Pain from bladder spasms.
- Belladonna and opium suppositories are
prescribed and administered to reduce bladder
spasms that cause pain after TURP. Bladder spasms
frequently accompany urologic procedures. Antispasmodics offer relief by eliminating or reducing
spasms. Antimicrobial drugs are used to treat an
infection. Belladonna and opium do not relieve
urine retention or urinary frequency.
A nursing assistant tells the nurse, “I think
the client is confused. He keeps telling me he has to
void, but that isn’t possible because he has a catheter
in place that is draining well.” Which of the
following responses would be most appropriate for
the nurse to make?
■ 1. “His catheter is probably plugged. I’ll irrigate
it in a few minutes.”
■ 2. “That’s a common complaint after prostate
surgery. The client only imagines the urge to
void.”
■ 3. “The urge to void is usually created by the
large catheter, and he may be having some
bladder spasms.”
■ 4. “I think he may be somewhat confused.”
- The indwelling urinary catheter creates the
urge to void and can also cause bladder spasms. The
nurse should ensure adequate bladder emptying by
monitoring urine output and characteristics. Urine
output should be at least 50 mL/hour. A plugged
catheter, imagining the urge to void, and confusion
are less likely reasons for the client’s complaint.
A physician has ordered amoxicillin 100
P.O. BID (Ampicillin). The nurse should teach the
client to: Select all that apply.
■ 1. Drink 2,500 mL of fl uids daily.
■ 2. Void frequently, at least every 2 to 3 hours.
■ 3. Take time to empty the bladder completely.
■ 4. Take the last dose of the antibiotic for the day
at bedtime.
■ 5. Take the antibiotic with food.
1, 2, 3, 4. Ampicillin may be given with or
without food, but the nurse should instruct the client
to obtain an adequate fl uid intake (2,500 mL)
to promote urinary output and to fl ush out bacteria
from the urinary tract. The nurse should also
encourage the client to void frequently (every 2 to
3 hours) and empty the bladder completely. Taking
the antibiotic at bedtime, after emptying the bladder,
helps to ensure an adequate concentration of the
drug during the overnight period.
In discussing home care with a client after
transurethral resection of the prostate (TURP), the
nurse should teach the male client that dribbling of
urine:
■ 1. Can be a chronic problem.
■ 2. Can persist for several months.
■ 3. Is an abnormal sign that requires intervention.
■ 4. Is a sign of healing within the prostate.
- Dribbling of urine can occur for several
months after TURP. The client should be informed
that this is expected and is not an abnormal sign.
The nurse should teach the client perineal exercises
to strengthen sphincter tone. The client may need
to use pads for temporary incontinence. The client should be reassured that continence will return in a
few months and will not be a chronic problem. Dribbling
is not a sign of healing, but is related to the
trauma of surgery.
A priority nursing diagnosis for the client
who is being discharged to home 3 days after transurethral
resection of the prostate (TURP) is:
■ 1. Defi cient fl uid volume.
■ 2. Imbalanced nutrition: Less than body requirements.
■ 3. Impaired tissue integrity.
■ 4. Ineffective airway clearance.
- Defi cient fl uid volume is a priority diagnosis
because the client needs to drink a large amount
of fl uids to keep the urine clear. The urine should
be almost without color. About 2 weeks after TURP,
when desiccated tissue is sloughed out, a secondary
hemorrhage could occur. The client should be
instructed to call the surgeon or go to the emergency
department if at any time the urine turns bright red.
The client is not specifi cally at risk for nutritional
problems after TURP. The client is not specifi cally at
risk for impaired tissue integrity because there is no
external incision, and the client is not specifi cally
at risk for airway problems because the procedure is
done under spinal anesthesia.
.
A client with benign prostatic hypertrophy
(BPH) has an elevated prostate-specifi c antigen
(PSA) level. The nurse should?
■ 1. Instruct the client to have a colonoscopy
before coming to conclusions about the PSA
results.
■ 2. Instruct the client that a urologist will monitor
the PSA level biannually when elevated.
■ 3. Determine if the prostatic palpation was done
before or after the blood sample was drawn.
■ 4. Ask the client if he emptied his bladder
before the blood sample was obtained.
- Rectal and prostate examinations can
increase serum PSA levels; therefore, instruct the
client that a manual rectal examination is usually
part of the test regimen to determine prostate
changes. The prostatic palpation should be done
after the blood sample is drawn. The PSA level must
be monitored more often than biannually when it is
elevated. Having a colonoscopy is not related to the
fi ndings of the PSA test. It is not necessary to void
prior to having PSA blood levels tested
A 28-year-old male is diagnosed with acute
epididymitis. The nurse should assess the client for:
■ 1. Burning and pain on urination.
■ 2. Severe tenderness and swelling in the scrotum.
■ 3. Foul-smelling ejaculate.
■ 4. Foul-smelling urine.
- Epididymitis causes acute tenderness and
pronounced swelling of the scrotum. Gradual onset
of unilateral scrotal pain, urethral discharge, and
fever are other key signs. Epididymitis is occasionally,
but not routinely, associated with urinary tract
infection. Burning and pain on urination and foulsmelling
ejaculate or urine are not classic symptoms
of epididymitis.
A 20-year-old client is being treated for
epididymitis. Teaching for this client should include
the fact that epididymitis is commonly a result of a:
■ 1. Virus.
■ 2. Parasite.
■ 3. Sexually transmitted infection.
■ 4. Protozoon.
- Among men younger than age 35,
epididymitis is most frequently caused by a sexually
transmitted infection. Causative organisms are usually
chlamydia or Neisseria gonorrhoeae. The other
major form of epididymitis is bacterial, caused by
the Escherichia coli or Pseudomonas organisms. The
nurse should always include safe sex teaching for a
client with epididymitis. The client should also be advised against anogenital intercourse because this
is a mode of transmission of gram-negative rods to
the epididymis.
- When teaching a client to perform testicular
self-examination, the nurse explains that the examination
should be performed:
■ 1. After intercourse.
■ 2. At the end of the day.
■ 3. After a warm bath or shower.
■ 4. After exercise.
- After a warm bath or shower, the testes
hang lower and are both relaxed and in the ideal
position for manual evaluation and palpation.
The nurse is assessing a client’s testes. Which
of the following fi ndings indicate the testes are
normal?
■ 1. Soft.
■ 2. Egg-shaped.
■ 3. Spongy.
■ 4. Lumpy.
- Normal testes feel smooth, egg-shaped,
and firm to the touch, without lumps. The surface
should feel smooth and rubbery. The testes should
not be soft or spongy to the touch. Testicular malignancies
are usually nontender, nonpainful hard
lumps. Lumps, swelling, nodules, or signs of infl ammation
should be reported to the physician.
- A client has a testicular nodule that is highly
suspicious for testicular cancer. A laboratory test
that supports this diagnosis is:
■ 1. Decreased alpha fetoprotein (AFP).
■ 2. Decreased beta–human chorionic gonadotropin
(hCG).
■ 3. Increased testosterone.
■ 4. Increased AFP.
- AFP and hCG are considered markers that
indicate the presence of testicular disease. Elevated
AFP and hCG and decreased testosterone are markers
for testicular disease. Measurements of AFP,
hCG, and testosterone are also obtained throughout
the course of therapy to help measure the effectiveness
of treatment.
Although the cause of testicular cancer is
unknown, it is associated with a history of:
■ 1. Undescended testes.
■ 2. Sexual relations at an early age.
■ 3. Seminal vesiculitis.
■ 4. Epididymitis.
- Cryptorchidism (undescended testes) carries
a greatly increased risk for testicular cancer.
Undescended testes occurs in about 3% of male
infants, with an increased incidence in premature
infants. Other possible causes of malignancy include
chemical carcinogens, trauma, orchitis, and environmental
factors. Testicular cancer is not associated
with early sexual relations in men, even though cervical
cancer is associated with early sexual relations
in women. Testicular cancer is not associated with
seminal vesiculitis or epididymitis.
Risk factors associated with testicular malignancies include: ■ 1. African-American race. ■ 2. Residing in a rural area. ■ 3. Lower socioeconomic status. ■ 4. Age older than 40 years.
- The incidence of testicular cancer is higher
in men who live in rural rather than suburban
areas. Testicular cancer is more common in white
than black men. Men with higher socioeconomic
status seem to have a greater incidence of testicular
cancer. The exact cause of testicular cancer is
unknown. Cancer of the testes is the leading cause
of death from cancer in the 15- to 35-year-old agegroup.
A client with a testicular malignancy undergoes a radical orchiectomy. In the immediate postoperative period the nurse should particularly assess the client for: ■ 1. Bladder spasms. ■ 2. Urine output. ■ 3. Pain. ■ 4. Nausea.
- Because of the location of the incision
in the high inguinal area, pain is a major problem
during the immediate postoperative period. The
incisional area and discomfort caused by movement
contribute to increased pain. Bladder spasms and
elimination problems are more commonly associated
with prostate surgery. Nausea is not a priority
problem.
sicles) may
A right orchiectomy is performed on a client
with a testicular malignancy. The client expresses
concerns regarding his sexuality. The nurse should
base the response on the knowledge that the client:
■ 1. Is not a candidate for sperm banking.
■ 2. Should retain normal sexual drive and function.
■ 3. Will be impotent.
■ 4. Will have a change in secondary sexual characteristics.
- Unilateral orchiectomy alone does not
result in impotence if the other testis is normal. The
other testis should produce enough testosterone
to maintain normal sexual drive, functioning, and
characteristics. Sperm banking before treatment is
commonly recommended because radiation or chemotherapy
can affect fertility.
A client diagnosed with seminomatous testicular
cancer expresses fear and questions the nurse
about his prognosis. The nurse should base the
response on the knowledge that:
■ 1. Testicular cancer is almost always fatal.
■ 2. Testicular cancer has a cure rate of 90% when
diagnosed early.
■ 3. Surgery is the treatment of choice for testicular
cancer.
■ 4. Testicular cancer has a 50% cure rate when
diagnosed early.
- When diagnosed early and treated aggressively,
testicular cancer has a cure rate of about
90%. Treatment of testicular cancer is based on
tumor type, and seminoma cancer has the best prognosis.
Modes of treatment include combinations of
orchiectomy, radiation therapy, and chemotherapy.
The chemotherapeutic regimen used currently is
responsible for the successful treatment of testicular
cancer.
The nurse is developing a program about
prostate cancer for a health fair. The nurse should
provide information about which of the following
topics?
■ 1. The Prostate-Specifi c Antigen (PSA) test is reliable
for detecting the presence of prostate cancer.
■ 2. For all men, age 50 and older, the American
Cancer Society recommends an annual rectal
examination.
■ 3. Avoid lifting more than 20 lb aids in prevention
of prostate cancer.
■ 4. Regular sexual activity promotes health of the
prostate gland to prevent cancer.
- Most prostate cancer is adenocarcinoma
and is palpable on rectal examination because
it arises from the posterior portion of the gland.
Although the PSA is not a perfect screening test, the
American Cancer Society recommends an annual
rectal examination and blood PSA level for all men
age 50 and older, or starting at age 40 if African
American or if there is family history of prostate
cancer. To help achieve optimal sexual function,
give the client the opportunity to communicate his
concerns and sexual needs. Regular sexual activity
does not prevent cancer.
The nurse is caring for a client who will
have a bilateral orchiectomy. The client asks what
is involved with this procedure. The nurse’s most
appropriate response would be? “The surgery:
■ 1. Removes the entire prostate gland, prostatic
capsule, and seminal vesicles.”
■ 2. Tends to cause urinary incontinence and
impotence.”
■ 3. Freezes prostate tissue, killing cells.”
■ 4. Results in reduction of the major circulating
androgen, testosterone.”
- Bilateral orchiectomy (removal of testes)
results in reduction of the major circulating androgen,
testosterone, as a palliative measure to reduce
symptoms and progression of prostate cancer.
A radical prostatectomy (removal of entire prostate
gland, prostatic capsule, and seminal vesicles) may include pelvic lymphadenectomy. Complications
include urinary incontinence, impotence, and rectal
injury with the radical prostatectomy. Cryosurgery
freezes prostate tissue, killing tumor cells without
prostatectomy.
The nurse is teaching a client newly diagnosed
with prostate cancer. Which of the following points
should be included in the instruction? Select all that
apply.
■ 1. Prostate cancer is usually multifocal and
slow-growing.
■ 2. Most prostate cancers are adenocarcinoma.
■ 3. The incidence of prostate cancer is higher
in African American men, and the onset is
earlier.
■ 4. A prostate specifi c antigen (PSA) lab
test greater than 4 ng/mg will need to be
monitored.
■ 5. Cancer cells are detectable in the urine.
1, 2, 3, 4. Cancer of the prostate gland is the
second-leading cause of cancer death among American
men and is the most common carcinoma in
men older than age 65. Incidence of prostate cancer
is higher in African American men, and onset is
earlier. Most prostate cancers are adenocarcinoma.
Prostate cancer is usually multifocal, slow-growing,
and can spread by local extension, by lymphatics, or
through the bloodstream. Prostate-specifi c antigen
(PSA) greater than 4 ng/mg is diagnostic; a free PSA
level can help stratify the risk of elevated PSA levels.
Metastatic workup may include skeletal x-ray,
bone scan, and CT or MRI to detect local extension,
bone, and lymph node involvement. The urine does
not have prostate cancer cells.
When a client is receiving hormone replacement
for prostate cancer, the nurse should do which
of the following? Select all that apply.
■ 1. Inform the client that increased libido is
expected with hormone therapy.
■ 2. Reassure the client and his signifi cant other
that erectile dysfunction will not occur as a
consequence of hormone therapy.
■ 3. Provide the client the opportunity to communicate
concerns and needs.
■ 4. Utilize communication strategies that
enable the client to gain some feeling of
control.
■ 5. Suggest that an appointment be made to see a
psychiatrist.
3, 4. Hormone manipulation deprives tumor
cells of androgens or their by-products and, thereby,
alleviates symptoms and retards disease progression.
Complications of hormonal manipulation
include: hot fl ashes, nausea and vomiting, gynecomastia,
and sexual dysfunction. As part of supportive
care, provide explanations of diagnostic tests
and treatment options and help the client gain some
feeling of control over his disease and decisions
related to it. To help achieve optimal sexual function,
give the client the opportunity to communicate
his concerns and sexual needs. Inform the client
that decreased libido is expected after hormonal
manipulation therapy, and that impotence may
result from some surgical procedures and radiation.
A psychiatrist is not needed.
A client asks the nurse why the prostate
specifi c antigen (PSA) level is determined before the
digital rectal examination. The nurse’s best response
is which of the following?
■ 1. “It is easier for the client.”
■ 2. “A prostate examination can possibly
decrease the PSA.”
■ 3. “A prostate examination can possibly
increase the PSA.”
■ 4. “If the PSA is normal, the client will not have
to undergo the rectal examination.”
- Manipulation of the prostate during the
digital rectal examination may falsely increase the
PSA levels. The PSA determination and the digital
rectal examination are both necessary as screening
tools for prostate cancer, and both are recommended
for all men older than age 50. Prostate cancer is the
most common cancer in men and the second leading
killer from cancer among men in the United
States. Incidence increases sharply with age, and
the disease is predominant in the 60- to 70-year-old
age-group.
The nurse is performing a digital rectal
examination. Which of the following fi nding is a
key sign for prostate cancer?
■ 1. A hard prostate, localized or diffuse.
■ 2. Abdominal pain.
■ 3. A boggy, tender prostate.
■ 4. A nonindurated prostate.
- On digital rectal examination, key signs
of prostate cancer are a hard prostate, induration of
the prostate, and an irregular, hard nodule. Accompanying
symptoms of prostate cancer can include
constipation, weight loss, and lymphadenopathy.
Abdominal pain usually does not accompany prostate
cancer. A boggy, tender prostate is found with
infection (e.g., acute or chronic prostatitis).
A client is undergoing a total prostatectomy
for prostate cancer. The client asks questions about
his sexual function. The best response by the nurse
is which of the following?
■ 1. “Loss of the prostate gland means that you
will be impotent.”
■ 2. “Loss of the prostate gland means that you
will be infertile and there will be no ejaculation.
You can still experience the sensations
of orgasm.”
■ 3. “Loss of the prostate gland means that you
will have no loss of sexual function and
drive.”
■ 4. “Loss of the prostate gland means that your
erectile capability will return immediately
after surgery.”
- Loss of the prostate gland interrupts the
flow of semen, so there will be no ejaculation fl uid.
The sensations of orgasm remain intact. The client
needs to be advised that return of erectile capability
is often disrupted after surgery, but within 1 year
95% of men have returned to normal erectile function
with sexual intercourse.
A 65-year-old client has been told by the physician
that his prostate cancer was graded at stage
IIB. The client inquires if this means he is going to
die soon. The best response by the nurse is which of
the following?
■ 1. “Prostate cancer at this stage is very slow
growing.”
■ 2. “Prostate cancer at this stage is very fast
growing.”
■ 3. “Prostate cancer at this stage has spread to the
bone.”
■ 4. “Prostate cancer at this stage is diffi cult to
predict.”
- Clients who have stage IA or IIB prostate
cancer have an excellent survival rate. Prostate
cancer is usually slow growing, and many men who
have prostate cancer do not die from it. A stage I or
II tumor is confi ned to the prostate gland and has
not spread to the extrapelvic region or bone.
A client with prostate cancer is treated with
hormone therapy consisting of diethylstilbestrol
(DES; Stilphostrol), 2 mg daily. The nurse should
instruct the client to expect to have:
■ 1. Tenderness of the scrotum.
■ 2. Tenderness of the breasts.
■ 3. Loss of pubic hair.
■ 4. Decreased blood pressure.
- Diethylstilbestrol causes engorgement and
tenderness of the breasts (gynecomastia). Stilbestrol
is prescribed as palliative therapy for men
with androgen-dependent prostatic carcinoma. An
increase in blood pressure can occur. Tenderness
of the scrotum and dramatic changes in secondary
sexual characteristics should not occur.
The client is taking sildenafi l (Viagra) P.O. for
erectile dysfunction. The nurse should instruct the
client about which of the following?
■ 1. Sildenafi l (Viagra) may be taken more than
one time per day.
■ 2. The health care provider should be notifi ed
promptly if the client experiences sudden or
diminished vision.
■ 3. Sildenafi l (Viagra) offers protection against
some sexually transmitted diseases (STDs).
■ 4. Sildenafi l (Viagra) does not require sexual
stimulation to work.
- Sildenafi l (Viagra) should not be taken
more than once per day. Viagra offers no protection
against sexually transmitted diseases. Viagra has no
effect in the absence of sexual stimulation. The client
should notify his health care provider promptly if he experiences sudden or decreased vision loss in
one or both eyes.
A male client complains of impotence. The
nurse examines the client’s medication regimen
and is aware that a contributing factor to impotence
could be:
■ 1. Aspirin.
■ 2. Antihypertensives.
■ 3. Nonsteroidal anti-infl ammatory drugs.
■ 4. Anticoagulants.
- Antihypertensives, especially beta blockers
such as propranolol (Inderal), can cause impotence.
When a male client complains of impotence,
the nurse should always examine his medication
regimen as a potential contributing factor. Aspirin nonsteroidal anti-infl ammatory drugs, and anticoagulants
do not cause erectile dysfunction.
A 65-year-old male client with erectile dysfunction
(ED) asks the nurse, “Is all this just in my
head? Am I crazy?” The best response by the nurse
is based on the knowledge that:
■ 1. ED is believed to be psychogenic in most
cases.
■ 2. More than 50% of the cases are attributed to
organic causes.
■ 3. Evaluation of nocturnal erections does not
help differentiate psychogenic or organic
causes.
■ 4. ED is an uncommon problem among men
older than age 65.
- ED is multifactorial in origin, and more
than 50% of the cases can be attributed to organic
causes, which include alteration in vascular supply,
hormonal changes, neurologic dysfunction,
medications, and associated systemic diseases, such
as diabetes mellitus or alcoholism. The presence of
nocturnal erections is the fi rst evaluation to differentiate
between organic and psychogenic causes. ED
is a common problem among men older than age 65.
The nurse should teach the client with erectile
dysfunction (ED) to alter his lifestyle to:
■ 1. Avoid alcohol.
■ 2. Follow a low-salt diet.
■ 3. Decrease smoking.
■ 4. Increase attempts at sexual intercourse.
- Avoidance of alcohol can improve the outcome
of therapy. Alcohol and smoking can affect a
man’s ability to have and maintain an erection. The
client should be encouraged to follow a healthy diet,
but no specifi c diet is associated with improvement
of sexual function. The client should cease smoking,
not just decrease smoking. Increasing attempts
at intercourse without treatment will not facilitate
improvement. The client should be reassured that
ED is a common problem and that help is available.
A 78-year-old client is admitted to the emergency department with numbness and
weakness of the left arm and slurred speech. Which nursing intervention is priority?
1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for a STAT computed tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult.
- A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular
accident (CVA). Which clinical manifestations would the nurse document?
1. Hemiparesis of the client’s left arm and apraxia.
2. Paralysis of the right side of the body and ataxia.
3. Homonymous hemianopsia and diplopia.
4. Impulsive behavior and hostility toward family.
- The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.
Which client would the nurse identify as being most at risk for experiencing a CVA?
- A 55-year-old African American male.
- An 84-year-old Japanese female.
- A 67-year-old Caucasian male.
- A 39-year-old pregnant female.
- African-Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups.
The client diagnosed with a right-sided cerebrovascular accident is admitted to the
rehabilitation unit. Which interventions should be included in the nursing care plan?
Select all that apply.
1. Position the client to prevent shoulder adduction.
2. Turn and reposition the client every shift.
3. Encourage the client to move the affected side.
4. Perform quadriceps exercises three (3) times a day.
5. Instruct the client to hold the fingers in a fist.
- Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture.
The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.
- Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture.
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular
accident. Which collaborative intervention will be included in the plan of care?
1. Observe the client swallowing for possible aspiration.
2. Position the client in a semi-Fowler’s position when sleeping.
3. Place a suction setup at the client’s bedside during meals.
4. Refer the client to an occupational therapist for evaluation.
.
- A collaborative intevention is an intervention in which another health care discipline - in this case, occupational therapy- is used in the care of the client.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with
right-sided paralysis. Which action by the UAP requires the nurse to intervene?
1. The assistant places a gait belt around the client’s waist prior to ambulating.
2. The assistant places the client on the back with the client’s head to the side.
3. The assistant places a hand under the client’s right axilla to move up in bed.
4. The assistant praises the client for attempting to perform ADLs independently.
- This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.
The client diagnosed with atrial fibrillation has experienced a transient ischemic
attack (TIA). Which medication would the nurse anticipate being ordered for the
client on discharge?
1. An oral anticoagulant medication.
2. A beta blocker medication.
3. An anti-hyperuricemic medication.
4. A thrombolytic medication.
- The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA.
The client has been diagnosed with a cerebrovascular accident (stroke). The client’s wife is concerned about her husband’s generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
- Obtain a rubber mat to place under the dinner plate.
- Purchase a long-handled bath sponge for showering.
- Purchase clothes with Velcro closure devices.
- Obtain a raised toilet seat for the client’s bathroom.
- Raising the toilet seat is modifying the home and addresses the client’s weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
- Potential for injury.
- Powerlessness.
- Disturbed thought processes.
- Sexual dysfunction.
- Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.
Which assessment data would indicate to the nurse that the client would be at risk
for a hemorrhagic stroke?
1. A blood glucose level of 480 mg/dL.
2. A right-sided carotid bruit.
3. A blood pressure of 220/120 mm Hg.
4. The presence of bronchogenic carcinoma.
- Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.
The 85-year-old client diagnosed with a stroke is complaining of a severe headache.
Which intervention should the nurse implement first?
1. Administer a nonnarcotic analgesic.
2. Prepare for STAT magnetic resonance imaging (MRI).
3. Start an intravenous infusion with D5W at 100 mL/hr.
4. Complete a neurological assessment.
- The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
- Administer a stool softener b.i.d.
- Encourage the client to cough hourly.
- Monitor neurological status every shift.
- Maintain the dopamine drip to keep BP at 160/90
- The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.
The client diagnosed with Parkinson’s disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data?
- Masklike facies and shuffling gait.
- Difficulty swallowing and immobility.
- Pill rolling of fingers and flat affect.
- Lack of arm swing and bradykinesia.
- Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications.
The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet),
an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications?
1. There will be fewer side effects with this combination than with carbidopa alone.
2. Dopamine D requires the presence of both of these medications to work.
3. Carbidopa makes more levodopa available to the brain.
4. Carbidopa crosses the blood–brain barrier to treat Parkinson’s Disease.
- Carbidopa enhances the effects of levodopa by inhibiting decarboxylase in the periphery, thereby making more levodopa available to the central nervous system. Sinemet is the most effective treatment for PD.
- The nurse caring for a client diagnosed with Parkinson’s disease writes a problem of
“impaired nutrition.” Which nursing intervention would be included in the plan of care? - Consult the occupational therapist for adaptive appliances for eating.
- Request a low-fat, low-sodium diet from the dietary department.
- Provide three (3) meals per day that include nuts and whole-grain breads.
- Offer six (6) meals per day with a soft consistency.
- The client’s energy levels will not sustain eating for long periods. Offering frequent and easy to chew (soft) meals of small proportions is the preferred dietary plan.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
1. Feed the 69-year-old client diagnosed with Parkinson’s disease who is having difficulty swallowing.
2. Turn and position the 89-year-old client diagnosed with a pressure ulcer
secondary to Parkinson’s disease.
3. Assist the 54-year-old client diagnosed with Parkinson’s disease with toilet-training
activities.
4. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson’s disease.
- The nurse should not delegate feeding a client who is at risk for complications during feeding. This requires judgement that the UAP is not expected to possess.
The charge nurse is making assignments. Which client should be assigned to the new graduate nurse?
- The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes.
- The client diagnosed with Parkinson’s disease who fell during the night and is complaining of difficulty walking.
- The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R 14, and BP 198/68.
- The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.
- Headache and photophobia are expected clinical manifestations of meningitis. The new graduate could care for this client.
The nurse is planning the care for a client diagnosed with Parkinson’s disease. Which would be a therapeutic goal of treatment for the disease process?
- The client will experience periods of akinesia throughout the day.
- The client will take the prescribed medications correctly.
- The client will be able to enjoy a family outing with the spouse.
- The client will be able to carry out activities of daily living.
- The major goal of treating PD is to maintain the ability to function. Clients diagnosed with PD experience slow, jerky movements and have difficulty performing routine daily tasks.
The nurse researcher is working with clients diagnosed with Parkinson’s disease. Which is an example of an experimental therapy?
- Sterotactic pallidotomy/thalamotomy.
- Dopamine receptor agonist medication.
- Physical therapy for muscle strengthening.
- Fetal tissue transplantation.
- Fetal tissue transplantation has shown some success in PD, but it is an experimental and highly controversial procedure.
The client diagnosed with Parkinson’s disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge
instructions?
1. “All of my spouse’s emotions will slow down now just like his body movements.”
2. “My spouse may experience hallucinations until the medication starts working.”
3. “I will schedule appointments late in the morning after his morning bath.”
4. “It is fine if we don’t follow a strict medication schedule on weekends.”
- Scheduling appointments late in the morning gives the client a chance to complete ADLs without pressure and allows the medications time to give the best benefits.
The nurse is admitting a client with the diagnosis of Parkinson’s disease. Which assessment data support this diagnosis?
1. Crackles in the upper lung fields and jugular vein distention.
2. Muscle weakness in the upper extremities and ptosis.
3. Exaggerated arm swinging and scanning speech.
4. Masklike facies and a shuffling gait.
.
- Masklike facies and a shuffling gait are two clinical manifestations of PD.
Which is a common cognitive problem associated with Parkinson’s disease?
- Emotional lability.
- Depression.
- Memory deficits.
- Paranoia.
- Memory deficits are cognitive impairments. The client may also develop a dementia.
The nurse is conducting a support group for clients diagnosed with Parkinson’s disease and their significant others. Which information regarding psychosocial needs
should be included in the discussion?
1. The client should discuss feelings about being placed on a ventilator.
2. The client may have rapid mood swings and become easily upset.
3. Pill-rolling tremors will become worse when the medication is wearing off.
4. The client may automatically start to repeat what another person says.
- These are psychosocial manifestations of PD. These should be discussed in the suppport meeting.
The nurse is caring for clients on a medical-surgical floor. Which client should be assessed first?
- The 65-year-old client diagnosed with seizures who is complaining of a headache that is a “2” on a 1-to-10 scale.
- The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes.
- The 58-year-old client diagnosed with Parkinson’s disease who is crying and worried about her facial appearance.
- The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis
- Body image is a concern for clients diagnosed with PD. This client is the one client who is not experiencing expected sequelae of the disease.
Which is the American Cancer Society’s recommendation for the early detection of
cancer of the prostate?
1. A yearly PSA level and DRE beginning at age 50.
2. A biannual rectal examination beginning at age 40.
3. A semiannual alkaline phosphatase level beginning at age 45.
4. A yearly urinalysis to determine the presence of prostatic fluid.
- The American Cancer Society recommends all men have a yearly prostate specific antigen blood level, followed by a digital rectal examination beginning at age 50. Men in the high-risk group, including all African American men, should begin at age 45.
The client is diagnosed with early cancer of the prostate. Which assessment data would the client report?
- Urinary urgency and frequency.
- Retrograde ejaculation during intercourse.
- Low back and hip pain.
- No problems have been noticed.
- In early stage prostate cancer, the man will not be aware of the disease. Early detection is achieved by screening for the cancer.
The 80-year-old male client has been diagnosed with cancer of the prostate. Which treatment should the nurse discuss with the client?
- Radiation therapy every day for four (4) weeks.
- Radical prostatectomy with lymph node dissection.
- Diethylstilbestrol (DES), an estrogen, daily.
- Penile implants to maintain sexual functioning.
- DES is a hormone preparation that suppresses the male hormones and slows the growth of the tumor. Some men with a life expectancy of less than 10 years choose not to treat cancer at all and will ususally die from causes other than prostate cancer.
The nurse writes a client problem of urinary retention for a client diagnosed with Stage IV cancer of the prostate. Which intervention should the nurse implement
first?
1. Catheterize the client to determine the amount of residual.
2. Encourage the client to assume a normal position for urinating.
3. Teach the client to use the Valsalva maneuver to empty the bladder.
4. Determine the client’s normal voiding pattern.
- Determining the client’s normal voiding patterns provides a baseline for the nurse and client to use when setting goals.
The client has undergone a bilateral orchiectomy for cancer of the prostate. Which intervention should the nurse implement?
- Support the scrotal sac with a towel and apply ice.
- Administer testosterone replacement hormone orally.
- Encourage the client to place sperm in a sperm bank.
- Have the client talk to another man with ejaculation dysfunction.
- Elevating a surgical site and applying ice will reduce edema to the area.
The client diagnosed with cancer of the prostate has been placed on luteinizing hormone–releasing hormone (LHRH) agonist therapy. Which statement indicates
the client understands the treatment?
1. “I will be able to function sexually as always.”
2. “I may have hot flashes while taking this drug.”
3. “This medication will cure the prostate cancer.”
4. “There are no side effects with this medication.”
- The client may have hot flashes because these drugs increase hypothalamic activity, which stimulates the thermoregulatory centers of the body
The client is diagnosed with metastatic prostate cancer to the bones. Which nursing intervention should the nurse implement?
- Prepare for a transurethral resection of the prostate.
- Keep the foot of the bed elevated at all times.
- Place the client on a scheduled bowel regimen.
- Discuss the client’s altered sexual functioning.
- Bone metastasis is very painful, and the client should be placed on a scheduled regimen of pain medication. Pain medication slows peristalis and causes constipation. The client should be placed on a routine bowel management program to prevent impactions.
Which could be a complication of cryotherapy surgery for cancer of the prostate?
- The urethra could become scarred and cause retention.
- The client could have ejaculation difficulties and be impotent.
- Bone marrow suppression could occur from the chemotherapy.
- Chronic vomiting and diarrhea causing electrolyte imbalance could occur.
- Cryotherapy involves placing freezing probes into the prostate to freeze th cancer cells. An indwelling catheter is placed into the urethra, and warm water is circulated through the catheter to try to prevent the urethra from freezing. If the urethra scars, then the lumen will constrict, causing retention of urine.
The client is eight (8) hours post–transurethral prostatectomy for cancer of the prostate. Which nursing intervention is priority at this time?
- Control postoperative pain.
- Assess abdominal dressing.
- Encourage early ambulation to prevent DVT.
- Monitor fluid and electrolyte balance.
- With irrigation of the surgical site through the indwelling three way catheter to prevent blood clots, fluids may be absorbed through the open surgical site and retained. This can lead to fluid volume overload and electrolyte imbalance (hyponatremia).
The client scheduled for a radical prostatectomy surgical procedure has an
intravenous antibiotic medication ordered on call to surgery. The antibiotic is
prepared in 100 mL of sterile normal saline. At what rate should the nurse infuse via
the IV pump to infuse the medication in 30 minutes when notified by the operating
room nurse? ________
200ml/hr.
The client diagnosed with cancer of the prostate tells the nurse, “I caused this by being promiscuous when I was young and now I have to pay for my sins.” Which
statement is the nurse’s most therapeutic response?
1. “Why would you think prostate cancer is caused by sex?”
2. “You feel guilty about some of your actions when you were young?”
3. “Well, there is nothing you can do about that behavior now.”
4. “Have you told the HCP and been checked for an AIDS infection?”
- The question asks for a therapeutic response from the nurse. This response is restating and clarifying.
The nurse is preparing the care plan for a 45-year-old client who has had a radical prostatectomy. Which psychosocial and physiological problem should be included in the plan? 1. Altered coping. 2. High risk for hemorrhage. 3. Sexual impotence. 4. Risk for electrolyte imbalance.
- This problem has both physiological and psychological implications.
The school nurse is preparing a class on testicular cancer for male high school seniors. Which information regarding testicular self-examination should the nurse
include?
1. Perform the examination in a cool room under a fan.
2. Any lump should be examined by an HCP as soon as possible.
3. Discuss having a second person confirm a negative result.
4. The procedure will cause mild discomfort if done correctly.
- The client may note a cordlike structure; this is the spermatic cord and is normal. Any lump or mass felt is abnormal and should be checked by an HCP as soon as possible.
The nurse empted 2,000 mL from the drainage bag of a continuous irrigation of a
client who had a transurethral resection of the prostate (TURP). The amount of
irrigation in the bag hanging was 3,000 mL at the beginning of the shift. There was
1,800 mL left in the bag eight (8) hours later. What is the correct urine output at the
end of the eight (8) hours? _________
800mL
The nurse enters the room of a 24-year-old client diagnosed with testicular cancer. The fiancée of the client asks the nurse, “Will we be able to have children?” Which is the nurse’s best response?
- “Your fiancée will be able to father children like always.”
- “You will have to adopt children because he will be sterile.”
- “You and he should consider sperm banking prior to treatment.”
- “Have you discussed this with your fiancée? I can’t discuss this with you.”
- Sperm banking will allow the client to father children through artificial insemination with the client’s sperm.
The client diagnosed with testicular cancer is scheduled for a unilateral orchiectomy. Which information is important to teach regarding sexual functioning?
- The client will have ejaculation difficulties after the surgery.
- The client will be prescribed male hormones following the surgery.
- The client may need to have a penile implant to be able to have intercourse.
- Libido and orgasm usually are unimpaired after this surgery.
- Sex drive (libido) and orgasms ususally are unimpaired because the client still has one testicle.
Which client has the highest risk for developing cancer of the testicles?
- The client diagnosed with epididymitis.
- The client born with cryptorchidism.
- The client with an enlarged prostate.
- The client diagnosed with hypospadias.
- Cryptorchidism is the medical term for undescended testicle. The testicles may be in the abdomen or inguinal canal at birth. This condition places the client at higher risk for testicular cancer.
The nurse is caring for a client who is eight (8) hours postoperative unilateral orchiectomy for cancer of the testes. Which intervention should the nurse implement?
- Provide an athletic supporter before ambulating.
- Encourage the client to delay use of pain medications.
- Place client on a clear liquid diet for the first 48 hours.
- Monitor the PT/INR levels and have vitamin K ready.
- The scrotum will require support during ambulation. An athletic supporter is designed to provide support to this area.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a genitourinary floor. Which nursing task can be delegated to the UAP?
- Increase the drip rate on the Murphy drip irrigation set.
- Check the suprapubic catheter insertion site for infection.
- Encourage the two (2)-hour postoperative client to turn and cough.
- Document the amount of red drainage in the catheter.
- The unlicensed assistive personnel can be asked to help a client turn, cough, and deep breathe. This requires the UAP to perform an action only, not to use judgement or to assess.
The nurse is caring for a client with epididymitis secondary to a chlamydia infection.
Which discharge instruction should the nurse discuss?
1. The sexual partner must be prescribed antibiotics.
2. Delay sexual intercourse for a minimum of three (3) months.
3. Expect the urine to have white clumps for one (1) to two (2) months.
4. Drainage from the scrotum is fine as long as there is no fever.
- Chlamydia is a sexually transmitted disease ususally silent in the male partner, but it can cause epididymitis. If both sexual partners are not treated, then the partner can reinfect the client.
The nurse is assessing a client with rule-out testicular cancer. Which assessment data support the client having testicular cancer?
- The client complains of pain when urinating.
- There is a chancre sore on the shaft of the penis.
- The client complains of heaviness in the scrotum.
- There is a red, raised rash on the testes.
- Classic signs of cancer of the testes are a mass on the testicle, painless enlargement of the testes, and heaviness of the scrotum or lower abdomen.
The 30-year-old male client diagnosed with germinal cell carcinoma of the testes asks the nurse, “What chance do I have? Should I end it all now?” Which response
by the nurse indicates an understanding of the disease process?
1. “God does not want you to give up hope and end it all now.”
2. “There is a good chance for survival with standard treatment options.”
3. “There may be little hope, but ending it all is not the answer.”
4. “You have a 50/50 chance of living for at least 5 years.”
- Testicular cancers have very good prognoses, and even if the tumor returns, there is a good prognosis for extended survival.
Which tumor marker information is used to follow the progress of a client diagnosed with testicular cancer? 1. CA-125. 2. Carcinogenic embryonic antigen (CEA). 3. DNA ploidy test. 4. Human chorionic gonadotropin (hCG).
- Tumor markers are substances synthesized by the tumor and released into the bloodstream. They can be used to follow the progress of the disease. Testicular cancers secrete hCG and alpha-fetoprotein.
The client diagnosed with cancer of the testes calls and tells the nurse he is having low back pain which does not go away with acetaminophen, a nonnarcotic analgesic. Which action should the nurse implement?
- Ask the client to come in to see the HCP for an examination.
- Tell the client to use a nonsteroidal anti-inflammatory drug instead.
- Inform the client this means the cancer has metastasized.
- Encourage the client to perform lower back–strengthening exercises.
- This information could signal the onset of symptoms of metastasis to the retroperitoneum. The HCP should see the client and discuss follow-up diagnostic tests.
The charge nurse is making rounds on the genitourinary surgery floor. Which action
by the primary nurse warrants immediate intervention?
1. The nurse elevates the scrotum of a client who has had an orchiectomy.
2. The nurse encourages the client to cough, although he complains of pain.
3. The nurse empties the client’s JP drain and leaves it rounded.
4. The nurse asks the unlicensed UAP to empty a catheter drainage bag.
- The Jackson Pratt drain is a drain attached to a bulb, and the bulb should remain compressed to apply gental suction to the surgical site.
The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative
TURP. Which intervention should the nurse implement?
1. Remove the indwelling catheter.
2. Titrate the NS irrigation to run faster.
3. Administer protamine sulfate IVP.
4. Administer vitamin K slowly.
- Increasing the irrigation fluid will flush out the clots and blood.
Which data support to the nurse the client’s diagnosis of acute bacterial prostatitis?
- Terminal dribbling.
- Urinary frequency.
- Stress incontinence.
- Sudden fever and chills.
- Clients with acute bacterial prostatitis will frequently experience a sudden onset of fever and chills. Clients with chronic prostatitis have milder symptoms.
Which intervention should the nurse include when preparing a teaching plan for the client with chronic prostatitis?
- Sit in a warm sitz bath for 10 to 20 minutes several times daily.
- Sit in the chair with the feet elevated for two (2) hours daily.
- Drink at least 3,000 mL of oral fluids, especially tea and coffee, daily.
- Stop broad-spectrum antibiotics as soon as the symptoms subside.
- The client should sit in a warm sitz bath for 10 to 20 minutes several times each day to provide comfort and assist with healing.
Which nursing diagnosis is priority for the client who has undergone a TURP?
- Potential for sexual dysfunction.
- Potential for an altered body image.
- Potential for chronic infection.
- Potential for hemorrhage.
- This is a potentially life threatening problem.
Which statement indicates discharge teaching has been effective for the client who is
postoperative TURP?
1. “I will call the surgeon if I experience any difficulty urinating.”
2. “I will take my Proscar daily, the same as before my surgery.”
3. “I will continue restricting my oral fluid intake.”
4. “I will take my pain medication routinely even if I do not hurt.”
- This indicates the teaching is effective.
The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP?
- Increase the irrigation fluid to clear clots from the tubing.
- Elevate the scrotum on a towel roll for support.
- Change the dressing on the first postoperative day.
- Teach the client how to care for the continuous irrigation catheter.
- Elevating the scrotum on a towel for support is a task which can be delegated to the UAP.
The client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement first?
- Call the surgeon to inform the HCP of the client’s complaint.
- Administer the client a narcotic medication for pain.
- Explain to the client this sensation happens frequently.
- Assess the continuous irrigation catheter for patency.
- The nurse should always assess any complaint before dismissing it as a commonly occurring problem.
The client who is postoperative TURP asks the nurse, “When will I know if I will be able to have sex after my TURP?” Which response is most appropriate by the nurse?
- “You seem anxious about your surgery.”
- “Tell me about your fears of impotency.”
- “Potency can return in six (6) to eight (8) weeks.”
- “Did you ask your doctor about your concern?”
- This is usually the length of time clients need to wait prior to having sexual intercourse; this is the information the client wants to know.
The client asks, “What does an elevated PSA test mean?” On which scientific rationale should the nurse base the response?
- An elevated PSA can result from several different causes.
- An elevated PSA can be only from prostate cancer.
- An elevated PSA can be diagnostic for testicular cancer.
- An elevated PSA is the only test used to diagnose BPH.
- An elevated PSA can be from urinary retention, BPH, prostate cancer, or prostate infarct.
The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement?
Select all that apply.
1. Assess the urine in the continuous irrigation drainage bag.
2. Decrease the irrigation fluid in the continuous irrigation catheter.
3. Lower the head of the bed while raising the foot of the bed.
4. Contact the surgeon to give an update on the client’s condition.
5. Check the client’s postoperative creatinine and BUN.
- The nurse should assess the drain postoperatively
- the head of the bed should be lowered and the foot should be raised to shunt blood to the central circulating system.
- the surgeon needs to be notified of the change in condition
The nurse is caring for a client with a TURP. Which expected outcome indicates the client’s condition is improving?
- The client is using the maximum amount allowed by the PCA pump.
- The client’s bladder spasms are relieved by medication.
- The client’s scrotum is swollen and tender with movement.
- The client has passed a large, hard, brown stool this morning.
- Bladder spasms are common, but being relieved with medication indicates the condition is improving.
A nurse is planning care for a 25-year-old
female client who has just been diagnosed with
human immunodefi ciency virus (HIV) infection.
The client asks the nurse, “How could this have
happened?” The nurse responds to the question
based on the most frequent mode of HIV transmission,
which is:
■ 1. Hugging an HIV-positive sexual partner without
using barrier precautions.
■ 2. Inhaling cocaine.
■ 3. Sharing food utensils with an HIV-positive
person without proper cleaning of the utensils.
■ 4. Having sexual intercourse with an HIVpositive
person without using a condom.
- HIV infection is transmitted through blood
and body fl uids, particularly vaginal and seminal
fl uids. A blood transfusion is one way the disease
can be contracted. Other modes of transmission
are sexual intercourse with an infected partner and
sharing I.V. needles with an infected person. Women now have the highest rate of newly diagnosed HIV
infection. Many of these women have contracted
HIV from unprotected sex with male partners. HIV
cannot be transmitted by hugging, inhaling cocaine,
or sharing utensils.
A client with human immunodeficiency
virus (HIV) infection is taking zidovudine (AZT).
The expected outcome of AZT is to:
■ 1. Destroy the virus.
■ 2. Enhance the body’s antibody production.
■ 3. Slow replication of the virus.
■ 4. Neutralize toxins produced by the virus.
- Zidovudine (AZT) interferes with replication
of HIV and thereby slows progression of HIV
infection to acquired immunodefi ciency syndrome
(AIDS). There is no known cure for HIV infection.
Today, clients are not treated with monotherapy
but are usually on triple therapy due to a muchimproved
clinical response. Decreased viral loads
with the drug combinations have improved the longevity
and quality of life in clients with HIV/AIDS.
AZT does not destroy the virus, enhance the body’s
antibody production, or neutralize toxins produced
by the virus.
The primary reason that a herpes simplex
virus (HSV) infection is a serious concern to a client
with human immunodefi ciency virus (HIV) infection
is that it:
■ 1. Is an acquired immunodeficiency virus
(AIDS)–defi ning illness.
■ 2. Is curable only after 1 year of antiviral
therapy.
■ 3. Leads to cervical cancer.
■ 4. Causes severe electrolyte imbalances.
of the thigh.
- HSV infection is one of a group of disorders
that, when diagnosed in the presence of HIV
infection, are considered to be diagnostic for AIDS.
Other AIDS-defi ning illnesses include Kaposi’s sarcoma;
cytomegalovirus of the liver, spleen, or lymph
nodes; and Pneumocystis carinii pneumonia. HSV
infection is not curable and does not cause severe
electrolyte imbalances. Human papillomavirus can
lead to cervical cancer.
In educating a client about human immunodeficiency virus (HIV), the nurse should take
into account the fact that the most effective method
known to control the spread of HIV infection is:
■ 1. Premarital serologic screening.
■ 2. Prophylactic treatment of exposed people.
■ 3. Laboratory screening of pregnant women.
■ 4. Ongoing sex education about preventive
behaviors.
- Education to prevent behaviors that cause
HIV transmission is the primary method of controlling
HIV infection. Behaviors that place people at
risk for HIV infection include unprotected sexual
intercourse and sharing of needles for I.V. drug
injection. Educating clients about using condoms
during sexual relations is a priority in controlling
HIV transmission.
A male client with human immunodeficiency
virus (HIV) infection becomes depressed and tells
the nurse: “I have nothing worth living for now.”
Which of the following statements would be the best
response by the nurse?
■ 1. “You are a young person and have a great deal
to live for.”
■ 2. “You should not be too depressed; we are
close to fi nding a cure for AIDS.”
■ 3. “You are right; it is very depressing to have
HIV.”
■ 4. “Tell me more about how you are feeling
about being HIV-positive.”
- The nurse should respond with a statement
that allows the client to express his thoughts
and feelings. After sharing feelings about their diagnosis, clients will need information, support,
and community resources. Statements of encouragement
or agreement do not provide an opportunity
for the client to express himself.
The nurse assesses the mouth and oral cavity
of a client with human immunodefi ciency virus
(HIV) infection because the most common opportunistic
infection initially presents as:
■ 1. Herpes simplex virus (HSV) lesions on the
lips.
■ 2. Oral candidiasis.
■ 3. Cytomegalovirus (CMV) infection.
■ 4. Aphthae on the gingiva.
- The most common opportunistic infection
in HIV infection initially presents as oral candidiasis,
or thrush. The client with HIV should always
have an oral assessment. HSV and CMV are opportunistic
infections that present later in acquired
immunodefi ciency syndrome. Aphthous stomatitis,
or recurrent canker sores, is not an opportunistic
infection, although the sores are thought to occur
more often when the client is under stress.
The nurse is administering Didanosine
(Videx) to a client with HIV. Before administering
this medication, the nurse should check which lab
test results? Select all that apply.
■ 1. Elevated serum creatinine.
■ 2. Elevated blood urea nitrogen (BUN).
■ 3. Elevated aspartate aminotransferase (AST).
■ 4. Elevated alanine aminotransferase (ALT).
■ 5. Elevated serum amylase.
3, 4, 5. The nurse should withhold the
medication and notify the physician immediately
if the client develops manifestations of pancreatitis
or hepatic failure including nausea and vomiting,
severe abdominal pain, elevated bilirubin, or
elevated serum enzymes (e.g., amylase, AST, ALT).
If both BUN and creatinine are elevated, the client
may have kidney disease.
The nurse is caring for a client from Southeast
Asia who has HIV-AIDS. The client does
not speak or comprehend the English language.
What should the nurse do to provide culturallyappropriate
care?
■ 1. Contact the hospital’s chaplain.
■ 2. Do an Internet search for the Joint United
Nations Programme on HIV/AIDS.
■ 3. Utilize language-appropriate interpreters.
■ 4. Ask a family member to obtain informed
consent.
- Interpreters are essential in enabling the
nurses’ communications to be understood accurately.
The chaplain may not know the client’s language.
The Joint United Nations Programme on HIV/
AIDS has the number of reported cases of AIDS. It
is not necessary for the family member to obtain
informed consent.
Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis?
A. “You will need to get rid of your pets.” Incorrect
B. “You should sleep in an air-conditioned room.” Correct
C. “You would do best to stay indoors during the winter months.”
D. “You will need to dust your house with a dry feather duster twice a week.”
Seasonal allergic rhinitis is most commonly caused by pollens from trees, weeds, and grasses. Airborne allergies can be controlled by sleeping in an air-conditioned room, daily damp dusting, covering the mattress and pillows with hypoallergenic covers, and wearing a mask outdoors.
Awarded 0.0 points out of 1.0 possible points.
2.
ID: 809642777
When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply)?
A. Grapes Correct B. Oranges C. Bananas Correct D. Potatoes Correct E. Tomatoes Correct
Because some proteins in rubber are similar to food proteins, some foods may cause an allergic reaction in people who are allergic to latex. The most common of these foods are bananas, avocados, chestnuts, kiwi fruit, tomatoes, water chestnuts, guava, hazelnuts, potatoes, peaches, grapes, and apricots.
Awarded 1.0 points out of 4.0 possible points.
3.
ID: 809541149
Ten days after receiving a bone marrow transplant, a patient develops a skin rash on his palms and soles, jaundice, and diarrhea. What is the most likely etiology of these clinical manifestations?
A. The patient is experiencing a type I allergic reaction.
B. An atopic reaction is causing the patient’s symptoms. Incorrect
C. The patient is experiencing rejection of the bone marrow.
D. Cells in the transplanted bone marrow are attacking the host tissue. Correct
The patient’s symptoms are characteristic of graft-versus-host-disease (GVHD) in which transplanted cells mount an immune response to the host’s tissue. GVHD is not a type I allergic response or an atopic reaction, and it differs from transplant rejection in that the graft rejects the host rather than the host rejecting the graft.
Awarded 0.0 points out of 1.0 possible points.
4.
ID: 809541169
A patient’s low hemoglobin and hematocrit have necessitated a transfusion of packed red blood cells (RBCs). Shortly after the first unit of RBCs starts to infuse, the patient develops signs and symptoms of a transfusion reaction. Which type of hypersensitivity reaction has the patient experienced?
A. Type I Incorrect
B. Type II Correct
C. Type III
D. Type IV
Transfusion reactions are characterized as a type II (cytotoxic) reaction in which agglutination and cytolysis occur. Type I hypersensitivity reactions are IgE-mediated reactions to specific allergens (e.g., exogenous pollen, food, drugs, or dust). Type III reactions are immune-complex reactions that occur secondary to antigen-antibody complexes. Type IV reactions are delayed cell-mediated immune response reactions.
Awarded 0.0 points out of 1.0 possible points.
5.
ID: 809541147
A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient’s immunotherapy, what is the nurse’s priority action?
A. Monitor the patient’s fluid balance. Incorrect
B. Assess the patient’s need for analgesia.
C. Monitor for signs and symptoms of an adverse reaction. Correct
D. Assess the patient for changes in level of consciousness.
When administering immunotherapy, it is imperative to closely monitor the patient for any signs of an adverse reaction. The high risk and significant consequence of an adverse reaction supersede the need to assess the patient’s fluid balance. Pain and changes in level of consciousness are not likely events when administering immunotherapy.
Awarded 0.0 points out of 1.0 possible points.
6.
ID: 809642787
A healthy 65-year-old man who lives at home is at the clinic requesting a “flu shot.” When assessing the patient, what other vaccinations should the nurse ask the patient about receiving (select all that apply)?
A. Shingles Correct B. Pneumonia Correct C. Meningococcal Incorrect D. Haemophilus influenzae type b (Hib) E. Measles, mumps, and rubella (MMR)
The patient should receive the shingles (heres zoster) vaccine, Pneumovax, and influenza. The other options do not apply to this patient. Meningococcal vaccination is recommended for adults at risk (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies). Adults born before 1957 are generally considered immune to measles and mumps. Haemophilus influenzae type b (Hib) vaccination is only considered for adults with selected conditions (e.g., sickle cell disease, leukemia, HIV infection or for those who have anatomic or functional asplenia) if they have not been previously vaccinated.
Awarded 0.0 points out of 2.0 possible points.
7.
ID: 809541167
On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response increases with age?
A. Autoimmune response Correct
B. Cell-mediated immunity
C. Hypersensitivity response
D. Humoral immune response
With aging, autoantibodies increase, which lead to autoimmune diseases (e.g., systemic lupus erythematosus, acute glomerulonephritis, rheumatoid arthritis, hypothyroidism). Cell-mediated immunity decreases with decreased thymic output of T cells and decreased activation of both T and B cells. There is a decreased or absent delayed hypersensitivity reaction. Immunoglobulin levels decrease and lead to a suppressed humoral immune response in older adults.
Awarded 1.0 points out of 1.0 possible points.
8.
ID: 809541139
A 21-year-old student had taken amoxicillin once as a child for an ear infection. She is given an injection of Penicillin V and develops a systemic anaphylactic reaction. What manifestations would be seen first?
A. Dyspnea Incorrect
B. Dilated pupils
C. Itching and edema Correct
D. Wheal-and-flare reaction
A systemic anaphylactic reaction starts with edema and itching at the site of exposure to the antigen. Shock can rapidly develop with rapid, weak pulse; hypotension; dilated pupils; dyspnea, and possible cyanosis. The wheal-and-flare reaction occurs with a localized anaphylactic reaction such as a mosquito bite.
Awarded 0.0 points out of 1.0 possible points.
9.
ID: 809541165
The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse’s first action?
A. Administer IV diphenhydramine (Benadryl). Incorrect
B. Administer nitroprusside as soon as possible.
C. Anticipate tracheostomy with laryngeal edema.
D. Place the patient recumbent and elevate the legs. Correct
In this emergency situation, the ABCs (airway, breathing, circulation) are being followed. For hypotension the patient should be placed in a recumbent position with the legs elevated, epinephrine will continue to be administered every 2-5 minutes, and fluids will be administered with vasopressors. Diphenhydramine is an antihistamine used to treat allergy symptoms. Anticipating a tracheostomy may occur with ongoing patient monitoring. Nitroprusside is a vasodilator and would not be used now.
Awarded 0.0 points out of 1.0 possible points.
10.
ID: 809541137
The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment?
A. It will gather platelets for use later when needed. Incorrect
B. It will cause anemia because it removes whole blood and RBCs are damaged.
C. It will remove the IgG autoantibodies and antigen complexes from the plasma. Correct
D. It will remove the peripheral stem cells in order to cure the autoimmune disease.
Plasmapheresis removes plasma that contains autoantibodies (usually IgG class) and antigen-antibody complexes to remove the pathologic substances in the plasma without causing anemia. Plateletpheresis removes platelets from normal individuals for use by patients with low platelet counts. Apheresis is used to collect stem cells from peripheral blood that does not cure autoimmune disease.
Awarded 0.0 points out of 1.0 possible points.
11.
ID: 809541145
The patient with diabetes mellitus has been ill for some time with a severe lung infection needing corticosteroids and antibiotics. The patient does not feel like eating. The nurse understands that this patient is likely to develop
A. major histoincompatibility. Incorrect
B. primary immunodeficiency.
C. secondary immunodeficiency. Correct
D. acute hypersensitivity reaction.
Secondary immunodeficiency is most commonly caused by immunosuppressive drugs, such as corticosteroids. It can also be caused by diabetes mellitus, severe infection, malnutrition, and chronic stress, all of which are present in this patient. The other options are not possible for this patient. Histoincompatibility occurs when the human leukocyte antigen (HLA) system of the donor is not compatible with the recipient’s HLA genes. Primary immunodeficiency is rare and includes phagocytic defects, B cell deficiency, T cell deficiency, or a combination of B cell and T cell deficiency. Acute hypersensitivity reaction is an anaphylactic-type allergic reaction to an antigen.
Awarded 0.0 points out of 1.0 possible points.
12.
ID: 809541151
Which statement by the patient who has had an organ transplant would indicate that the patient understands the teaching about the immunosuppressive medications?
A. “My drug dosages will be lower because the medications enhance each other.” Incorrect
B. “Taking more than one medication will put me at risk for developing allergies.”
C. “I will be more prone to malignancies because I will be taking more than one drug.”
D. “The lower doses of my medications can prevent rejection and minimize the side effects.” Correct
Because immunosuppressants work at different phases of the immune response, lower doses of each drug can be used to produce effective immunosuppression while minimizing side effects. The use of several medications is not because they enhance each other and does not increase the risk of allergies or of malignancies.
Awarded 0.0 points out of 1.0 possible points.
a
