Nursing Elites

1. An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurse's most appropriate response to the patient's complaint?

• A. Call 911.
• B. Promptly refer the patient for medical assessment.
• C. Facilitate a radiograph of the patient's neck and have the results forwarded to the patient's primary care provider.
• D. Encourage the patient to track the size of the lymph node and seek care in 1 week.

Correct answer: B

Rationale: The most appropriate response for a patient presenting with a firm, painless cervical lymph node and denying recent infectious diseases is to promptly refer the patient for medical assessment. This is crucial to rule out serious underlying conditions such as malignancy or other concerning causes. Calling 911 is not necessary in this situation as it is not an emergency. Ordering a radiograph may not be the most immediate or appropriate action, as further evaluation by a healthcare provider is needed first. Encouraging the patient to wait and track the lymph node for a week is not advisable when a potential serious condition needs to be ruled out promptly.

2. A nurse is preparing health education for a patient who has received a diagnosis of myelodysplastic syndrome (MDS). Which of the following topics should the nurse prioritize?

• A. Techniques for energy conservation and activity management
• B. Emergency management of bleeding episodes
• C. Technique for the administration of bronchodilators by metered-dose inhaler
• D. Techniques for self-palpation of the lymph nodes

Correct answer: B

Rationale: Because of patients risks of hemorrhage, patients with MDS should be taught techniques for managing emergent bleeding episodes.

3. The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?

• A. Fatigue related to altered metabolic processes
• B. Altered nutrition: less than body requirements related to anorexia
• C. Risk for infection related to altered immunologic response
• D. Body image disturbance related to weight loss and anorexia

Correct answer: C

Rationale: Patients preparing for hematopoietic stem cell transplantation (HSCT) undergo intensive chemotherapy and/or radiation, which significantly suppresses their immune system. This immunosuppression leads to a heightened risk for infection, making it the most critical nursing diagnosis for these patients. As the body’s ability to fight off pathogens is compromised, close monitoring and interventions aimed at preventing infections are essential for their safety and recovery.

4. The patient is anxious about subjection to radiation therapy. Which of the following statements of the student nurse requires additional teaching?

• A. Teletherapy is radiation from an external source.
• B. Brachytherapy can be administered via oral or IV.
• C. Brachytherapy is a radiation from inside the patient's body.
• D. Chemotherapy is effective in killing all cancer cells.

Correct answer: D

Rationale: The correct answer is D because the statement 'Chemotherapy is effective in killing all cancer cells' is incorrect. Chemotherapy does not kill all cancer cells and is not the same as radiation therapy. Chemotherapy targets rapidly dividing cells, including cancer cells, but it may not kill every single cancer cell. It is important for the student nurse to understand and communicate this distinction to the patient. Choices A, B, and C provide accurate information about teletherapy, brachytherapy, and chemotherapy, respectively, and do not require additional teaching.

5. Nurse Farah is caring for a client following a mastectomy. Which assessment finding indicates that the client is experiencing a complication related to the surgery?

• A. Pain at the incision site
• B. Arm edema on the operative side
• C. Sanguineous drainage in the Jackson-Pratt drain
• D. Complaints of decreased sensation near the operative site

Correct answer: B

Rationale: Arm edema on the operative side (lymphedema) is a known complication after a mastectomy. This can indicate impaired lymphatic drainage, leading to fluid accumulation in the arm. Pain at the incision site is expected postoperatively and may not necessarily indicate a complication. Sanguineous drainage in the Jackson-Pratt drain is a common finding in the immediate postoperative period. Complaints of decreased sensation near the operative site could be related to nerve damage or surgical manipulation, but it is not a typical complication after a mastectomy.

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