a client is diagnosed as having a positive reaction to the mantoux test which of the following is the most appropriate nursing action
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Nursing Elites

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Oncology Questions

1. A client is diagnosed as having a positive reaction to the Mantoux test. Which of the following is the most appropriate nursing action?

Correct answer: C

Rationale: The correct answer is to schedule the client for a chest x-ray. A positive Mantoux test indicates exposure to TB, but it does not confirm active disease. A chest x-ray is necessary to assess the presence of active TB disease. Isolating the client in a private room (Choice A) is not necessary based solely on a positive Mantoux test result. Administering isoniazid (INH) (Choice B) or beginning a 9-month course of medication therapy (Choice D) is premature without confirming active TB through a chest x-ray.

2. Nurse Joy is caring for a client with an internal radiation implant. When caring for the client, the nurse should observe which of the following principles?

Correct answer: B

Rationale: Clients with internal radiation implants (also known as brachytherapy) emit a small amount of radiation, which can pose a risk to others. Pregnant women are particularly vulnerable to the harmful effects of radiation because it can affect both the mother and the developing fetus. Radiation exposure can lead to birth defects, miscarriage, or other developmental issues, so pregnant women should avoid any exposure by not entering the client's room.

3. The nurse is caring for a female client experiencing neutropenia as a result of chemotherapy and develops a plan of care for the client. The nurse plans to:

Correct answer: C

Rationale: In clients experiencing neutropenia due to chemotherapy, the immune system is significantly compromised, leaving the client highly susceptible to infections. Meticulous hand hygiene is one of the most effective ways to prevent infections in neutropenic patients. Teaching the client and their family the importance of frequent and proper handwashing helps reduce the transmission of harmful pathogens that could lead to severe infections in the neutropenic client. This simple but essential intervention is crucial in maintaining a safe environment.

4. You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the patient the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer?

Correct answer: A

Rationale: The correct answer is A: Palliative. Palliative surgery is aimed at relieving symptoms and improving quality of life when a cure is not possible. In this scenario, where the cancer has recurred and metastasized, the goal of surgery would be to alleviate symptoms rather than to cure the disease. Choices B, C, and D are incorrect because reconstructive surgery aims to restore function or appearance, salvage surgery aims to remove or salvage tissue to prevent further complications, and prophylactic surgery aims to prevent the development of a condition rather than treat its progression.

5. A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?

Correct answer: A

Rationale: Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by an abnormally high platelet count, which increases the risk of hypercoagulation and thrombosis (blood clot formation). These clots can impair blood flow to tissues, leading to ineffective tissue perfusion. Thrombotic events, such as strokes, deep vein thrombosis, or myocardial infarctions, are common complications of ET, making Risk for Ineffective Tissue Perfusion the most critical nursing diagnosis to prioritize. The goal of nursing interventions will be to prevent clot formation and ensure adequate blood flow to tissues.

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