Cancer Nursing Care Management Study Guide

Jen has always been curious about the vast bruises that keep on sprouting all over her body. They do not cause her any alarm, however, as they are not painful and just fades away over time. Jen also noticed that she is unusually pale and most often experienced episodes of dizziness to the point of fainting. Her gums bleed spontaneously, sometimes her nose does. Lately, she always feels fatigued and out of breath. A trip to the physician and some laboratory tests confirmed her diagnosis of acute leukemia.

Epidemiology


Overall, the incidence of cancer is higher in men than in women and higher in industrialized sectors and nations.

  • More than 1.4 million Americans are diagnosed each year with cancer, affecting one of various body sites.
  • Cancer is second only to cardiovascular disease as a leading cause of death in the United States.
  • Although the number of cancer deaths has decreased slightly, more than 560, 000 Americans were expected to die from a malignant process in 2008.
  • The leading causes of cancer deaths in the United States, in order of frequency, are lung, prostate, and colorectal cancer in men and lung, breast, and colorectal cancer women.
  • For all cancer sites combined, African American men have a 15% higher incidence rate and a 38% higher death rate than Caucasian men.
    African-American women have a 9% lower incidence rate, but an 18% higher death rate than Caucasian women for all cancer sites combined.

Pathophysiology


Cancer is a disease process that begins when an abnormal cell is transformed by the genetic mutation of the cellular DNA.

  • Proliferative patterns. Cancerous cells are described as malignant neoplasms because they demonstrate uncontrolled cellular growth that follows no physiologic demand (neoplasia).
  • Characteristics of malignant cells. Cells are undifferentiated and often bear little resemblance to the normal cells; they grow at the periphery and sends out processes that infiltrate and destroy the surrounding tissues; the rate of their growth is variable and depends on level of differentiation; they can gain access to the blood and lymphatic channels and metastasizes to other areas of the body; they often cause generalized effects such as anemia, weakness, and weight loss; they often cause extensive tissue damage and causes death unless growth can be controlled.
  • Invasion and metastasis. Malignant disease processes have the ability to allow the spread or transfer of cancerous cells from one organ or body part to another by invasion (growth of the primary tumor into the surrounding host tissues) and metastasis (dissemination or spread of malignant cells from the primary tumor to distant sites.
  • Carcinogenesis. Carcinogenesis is a malignant transformation that involves initiation (initiators such as chemicals, physical factors, and biologic agents, escape normal enzymatic mechanisms and alter the genetic structure of the cellular DNA), promotion (repeated exposure to cocarcinogens causes the expression of abnormal or mutant genetics information), and progression (the altered cells exhibit increased malignant behavior).
  • Role of the immune system. Some evidence indicates that the immune system can detect the development of malignant cells and destroy them before cell growth becomes uncontrolled, but when the immune system fails to identify and stop the growth of malignant cells, clinical cancer develops.

Detection and Prevention of Cancer


Nurses and physicians have traditionally been involved with tertiary prevention, the care, and rehabilitation of patients after cancer diagnosis and treatment, but the American Cancer Society, the National Cancer Institute, clinicians, and researchers also place emphasis on primary and secondary prevention of cancer.

  • Primary prevention. Primary prevention is concerned with reducing risks of disease through health promotion strategies.
  • Secondary prevention. Secondary prevention programs promote screening and early detection activities such as breast and testicular self-examination and Papanicolaou (Pap) tests.

Diagnosis of Cancer


A cancer diagnosis is based on the assessment of physiologic and functional changes and results of the diagnostic evaluation.

  • Tumor marker identification. Analysis of substances found in body tissues, blood or other body fluids that are made by the tumor or by the body in response to the tumor.
  • Genetic profiling. Analysis for the presence of mutations in genes found in tumors or body tissues.
  • Mammography. Mammography is the use of x-ray images of the breast.
  • Magnetic resonance imaging (MRI). MRI uses magnetic fields and radio-frequency signals to create sectioned images of various body structures.
  • Computed tomography (CT). CT scan uses narrow-beam x-ray to scan successive layers of tissue for a cross-sectional view.
  • Fluoroscopy. Use of X-rays that identify contrasts in the body tissue densities; may involve the use of contrast agents.
  • Ultrasonography. Ultrasound uses high-frequency sound waves echoing off body tissues and is converted electronically into images; used to assess deep tissues within the body.
  • Endoscopy. Direct visualization of a body cavity or passageway by insertion of an endoscope into a body cavity or opening; allows tissue biopsy, fluid aspiration, and excision of small tumors.
  • Nuclear medicine imaging. Uses intravenous injection or ingestion of radioisotope substances followed by imaging of tissues that have concentrated the radioisotopes.
  • Positron emission tomography (PET). Through the use of a tracer, provides black and white or color-coded images of the biologic activity of a particular area, rather than its structure.
  • PET fusion. Use of a PET scanner and a CT scanner in one machine to provide an image combining anatomic detail, spatial resolution, and functional metabolic abnormalities.
  • Radioimmunoconjugates. Monoclonal antibodies are labeled with a radioisotope and injected intravenously into the patient.

Tumor Staging and Grading


A complete diagnostic evaluation include identifying the stage and grade of the tumor.
Staging. Staging determines the size of the tumor and the existence of local invasion and distant metastasis.

  • Tumor, nodes, and metastasis (TNM) system. The TNM system is frequently used, where T is the extent of the primary tumor, N is the absence or presence and extent of regional lymph node metastasis, and M is the absence or presence of distant metastasis.
  • Grading. Grading refers to the classification of the tumor cells, and it seeks to define the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and histologic characteristics of the tissue of origin.
  • Grade I to IV. Grade I tumors, also known as well-differentiated tumors, closely resemble the tissue of origin in structure and function while Grade IV tumors do not clearly resemble the tissue of origin in structure and function.

Management of Cancer


Treatment options offered to cancer patients should be based on treatment goals for each specific type of cancer.

Surgery

Surgical removal of entire cancer remains the ideal and most frequently used treatment method.

Diagnostic Surgery

Biopsy

  • Biopsy. Biopsy is usually performed to obtain a tissue sample for analysis of the cells suspected to be malignant.
  • Types of biopsy. The three most common biopsy methods are the excisional, incisional, and needle methods.
  • Excisional biopsy. Excisional biopsy is most frequently used for easily accessible tumors of the skin, breast, and upper and lower gastrointestinal and upper respiratory tracts.
  • Incisional biopsy. Incisional biopsy is performed if the tumor mass is too large to be removed.
  • Needle biopsy. Needle biopsies are performed to sample suspicious masses that are easily accessible, such as growths in the breasts, thyroid, lung, liver, and kidney.

Surgery as Primary Treatment

When surgery is the primary approach in treating cancer, the goal is to remove the entire tumor or as much as is feasible and any involved surrounding tissue, including regional lymph nodes.

  • Local excision. Local excision, often performed on an outpatient basis, is warranted when the mass is small, and it includes removal of the mass and a small margin of normal tissue that is easily accessible.
  • Wide or radical excisions. Wide excisions include removal of the primary tumor, lymph nodes, adjacent involved structures, and surrounding tissues that may be at high risk for tumor spread.
  • Video-assisted endoscopic surgery In this minimally invasive procedure, an endoscope with intense lighting and an attached multichip mini-camera is inserted into the body through a small incision.
  • Salvage surgery. Salvage surgery is an additional treatment option that is an extensive surgical approach to treat the local recurrence of cancer after the use of a less extensive primary approach.
  • Electrosurgery. Uses electric current to destroy tumor cells.
  • Cryosurgery. Uses liquid nitrogen or a very cold probe to freeze tissue and cause cell destruction.
  • Chemosurgery. Uses chemicals or chemotherapy applied directly to the tissue to cause destruction.
  • Laser surgery. Uses light and energy aimed at an exact tissue location and depth to vaporize cancer cells.
  • Photodynamic therapy. Intravenous administration of a light-sensitizing agent that is taken up by cancer cells, followed by exposure to laser within 24-48 hours.
  • Radiofrequency ablation. Uses localized application of thermal energy that destroys cancer cells through heat.

Prophylactic Surgery

Prophylactic surgery involves removing nonvital tissues or organs that are at increased risk to develop cancer.

  • Examples of prophylactic surgery. Colectomy, mastectomy, and oophorectomy are examples of prophylactic surgery.
  • Qualified patients. Prophylactic surgery is offered selectively to patients and discussed thoroughly with patients and families.

Palliative Surgery

When a cure is not possible, the goals of treatment are to make the patient as comfortable as possible.

  • Palliative surgery. Palliative surgery is performed in an attempt to relieve complications of cancer.
  • Communication. Honest and informative communication with the patient and family about the goal of surgery is essential to avoid false hope and disappointment.

Reconstructive Surgery

Reconstructive surgery may follow curative or radical surgery.

  • Reconstructive surgery. Reconstructive surgery may be performed in an attempt to improve function or obtain a more desirable cosmetic effect.
  • Indications. Reconstructive surgery may be indicated for breast, head and neck, and skin cancers.

Radiation Therapy

More than half of patients with cancer receive a form of radiation therapy at some point during treatment.

  • Uses. Radiation may be used to cure cancer, as in thyroid carcinomas, localized cancers of the head and neck, and cancers of the uterine cervix; it may control malignant disease when a tumor cannot be removed surgically or when local nodal metastasis is present, or it can be used neoadjuvantly.
  • Types. Two types of ionizing radiation-electromagnetic radiation (xrays and gamma rays) and particulate radiation (electrons, beta particles, protons, neutrons, and alpha particles)- can lead to tissue disruption.

Radiation Dosage

Radiation dosage depends on the sensitivity of the target tissues to radiation, the size of the tumor, tissue tolerance of the surrounding normal tissues, and critical structures adjacent to the tumor target.

  • Lethal tumor dose. The lethal tumor dose is defined as that dose that will eradicate 95% of the tumor yet preserve normal tissue.
  • Fractions. In external beam radiation, the total radiation dose is delivered over several weeks in daily doses called fractions.
  • Fractionated doses. Repeated radiation treatments over time also allow for the periphery of the tumor to be reoxygenated repeatedly, because tumors shrink from the outside inward.

Administration of Radiation

Radiation therapy can be administered in a variety of ways depending on the source of radiation used, the location of the tumor, and the type of cancer targeted.

  • Teletherapy (external beam radiation). External beam radiation therapy is the most commonly used form of radiation, in which, depending on the size, shape, and location of the tumor, different energy levels are generated to produce a carefully shaped beam that will destroy the targeted tumor, yet spare the surrounding healthy tissues and organs in an effort to reduce the treatment toxicities for the patient.
  • Brachytherapy (internal radiation). Internal radiation implantation, or brachytherapy, delivers a high dose of radiation to a localized area and can be implanted by means of needles, seeds, beads, or catheters into body cavities (vagina, abdomen, pleura) or interstitial compartments (breast, prostate).

Toxicity

  • Alopecia. Altered skin integrity is a common effect and can include alopecia or hair loss.
  • Stomatitis. Alterations in oral mucosa secondary to radiation therapy include stomatitis or inflammation of the oral tissues, xerostomia or dryness of the mouth, change and loss of taste, and increased salivation.
  • Thrombocytopenia. Bone marrow cells proliferate rapidly, and if sites containing bone marrow are included in the radiation field, anemia, leukopenia, and thrombocytopenia may result.

Nursing Management in Radiation Therapy

  • Assessment. The nurse assesses the patient’s skin and oropharyngeal mucosa regularly when radiation therapy is directed to these areas, and also the nutritional status and general well-being should be assessed.
  • Symptoms. If systemic symptoms, such as weakness and fatigue, occur, the nurse explains that these symptoms are a result of the treatment and do not represent deterioration or progression of the disease.
  • Safety precautions. Safety precautions used in caring for a patient receiving brachytherapy include  assigning the patient to a private room, posting appropriate notices about radiation safety precautions, having staff members wear dosimeter badges, making sure that pregnant staff members are not assigned to the patient’s care, prohibiting visits by children and pregnant visitors, limiting visits from others to 30 minutes daily, and seeing that visitors maintain a 6 foot distance from the radiation source.

Chemotherapy


In chemotherapy, antineoplastic agents are used in an attempt to destroy tumor cells by interfering with cellular functions, including replication.

  • Goal. The goal of treatment is the eradication of enough tumor so that the remaining tumor cells can be destroyed by the body’s immune system.
  • Proliferating cells. Actively proliferating cells within a tumor are the most sensitive to chemotherapeutic agents.
  • Nondividing cells. Nondividing cells capable of future proliferation are the least sensitive to antineoplastic medications and consequently are potentially dangerous.
  • Cell cycle-specific. Cell cycle-specific agents destroy cells that are actively reproducing by means of the cell-cycle; most affect cells in the S phase by interfering with DNA and RNA synthesis.
  • Cell cycle-nonspecific. Chemotherapeutic agents that act independently of the cell cycle phases are cell cycle nonspecific, and they usually have a prolonged effect on cells, leading to cellular damage and death.

Antineoplastic Agents

Chemotherapeutic agents are also classified by chemical group, each with a different mechanism of action.

  • Alkylating agents. Alters DNA structure by misreading DNA code, initiating breaks in the DNA molecule, cross-linking DNA strands
  • Nitrosoureas. Similar to the alkylating agents, but they can cross the bloodbrain barrier.
  • Topoisomerase I inhibitors. Induce breaks in the DNA strand by binding to enzyme topoisomerase I, preventing cells from dividing.
  • Antimetabolites. Antimetabolites interfere with the biosynthesis of metabolites or nucleic acids necessary for RNA and DNA synthesis.
  • Antitumor antibiotics. Interfere with DNA synthesis by binding DNA and prevent RNA synthesis.
  • Mitotic spindle poisons. Arrest metaphase by inhibiting mitotic tubular formation and inhibiting DNA and protein synthesis.
  • Hormonal agents. Hormonal agents bind to hormone receptor sites that alter cellular growth; blocks binding of estrogens to receptor sites; inhibit RNA synthesis; suppress aromatase of P450 system, which decreases level.

Nursing Management in Chemotherapy


Nurses play an important role in assessing and managing many of the problems experienced by patients undergoing chemotherapy.

  • Assessing fluid and electrolyte balance. Anorexia, nausea, vomiting, altered taste, mucositis, and diarrhea put patients at risk for nutritional and fluid electrolyte disturbances.
  • Modifying risks for infection and bleeding. Suppression of the bone marrow and immune system is expected and frequently serves as a guide in determining appropriate chemotherapy dosage but increases the risk of anemia, infection, and bleeding disorders.
  • Administering chemotherapy. The patient is observed closely during its administration because of the risk and consequences of extravasation, particularly of vesicant agent.
  • Protecting caregivers. Nurses must be familiar with their institutional policies regarding personal protective equipment, handling and disposal of chemotherapeutic agents and supplies, and management of accidental spills or exposures.

Bone Marrow Transplantation


The role of bone marrow transplantation (BMT) for malignant and some nonmalignant diseases continues to grow.

Type of Bone Marrow Transplant

Types of BMT based on the source of donor cells include:

  • Allogeneic. Allogeneic is from a related donor other than the patient; donor may be a related donor or a matched unrelated donor.
  • Autologous. Autologous BMT is from the patient himself.
  • Syngeneic. Syngeneic BMT  is from an identical twin.

Nursing Management in Bone Marrow Transplantation

Nursing care of patients undergoing BMT is complex and demands a high level of skill.

  • Implementing pretransplantation care. Nutritional assessments, extensive physical examinations, organ function tests, and psychological evaluations are conducted, with blood work that includes assessing past antigen exposure, and the patient’s support system, financial, and insurance resources are also evaluated.
  • Providing care during treatment. Nursing management during bone marrow infusion or stem cell infusions consists of monitoring the patient’s vital signs and blood oxygen saturation; assessing for adverse effects such as fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea, vomiting, hypotension, or hypertension, tachycardia, anxiety, and taste changes; and providing ongoing support and patient teaching.
  • Providing posttransplantation care. Ongoing nursing assessments such as psychosocial assessments in follow-up visits are essential to detect late effects of therapy after BMT, which occur 100 days or more after the procedure, and donors also require nursing care through being assisted in maintaining realistic expectations of themselves as well as of the patient.

Targeted Therapies


Targeted therapies seek to minimize the negative effects on healthy tissues by disrupting specific cancer cell functions such as malignant transformation, cell communication pathways, processes for growth and metastasis, and genetic coding.

Biologic Response Modifiers (BRM)

Biologic response modifier therapy involves the use of naturally occurring or recombinant agents or treatment methods that can alter the immunologic relationship between the tumor and the host to provide a therapeutic benefit.

  • Nonspecific biologic response modifiers. Nonspecific agents such as Calmette-Guérin (BCG) and Corynebacterium parvum, when injected into the patient, may serve as antigens that can stimulate an immune response in the hopes of eradicating malignant cells.
  • Monoclonal antibodies. Monoclonal antibodies (MoAbs) have become available through technologic advances, and this type of specificity allows MoAbs to destroy the cancer cells and spare normal cells.
  • Cytokines. Cytokines, substances produced by cells of the immune system to enhance the production and functioning of components of the immune system, are also the focus of cancer treatment research.
  • Retinoids. Retinoids are vitamin A derivatives that play a role in growth, reproduction, apoptosis, epithelial cell differentiation, and immune function, wherein specific receptors in the cell nucleus are retinoid-dependent, thus when retinoids bind with these receptors, cell differentiation and replication are affected.
  • Cancer vaccines. Cancer vaccines are used to mobilize the body’s immune response to recognize and attack cancer cells, as these cancer vaccines contain either portions of cancer cells alone or portions of cells in combination with other substances that can augment or boost immune responses.

Nursing Management in Biologic Response Modifier Therapy

It is essential for the nurse to assess the need for education, support, and guidance for both the patient and the family and assist in planning and evaluating patient care.

  • Monitoring therapeutic and adverse effects. The nurse must be familiar with each agent given and its potential effects, and also, the nurse must be aware of the impact of these side effects on the patient’s quality of life.
  • Promoting home and community-based care. The nurse teaches the patient and family how to administer BRMs through subcutaneous injections, provides instructions about side effects and helps the patient and family identify the strategies to manage many of the common side effects of BRM therapy.

Gene Therapy

Gene therapy includes approaches that correct genetic defects or manipulate genes to induce tumor cell destruction in the hope of preventing or combating the disease.

  • Challenges. One of the challenges confronting cancer gene therapy is the multiple somatic mutations involved in the development of cancer, making it difficult to identify the most effective gene therapy approach.
  • Viruses. Viruses used as vectors that transport a gene into a target cell via the cell membrane include retroviruses, adenoviruses, vaccinia virus, fowlpox, herpes simplex viruses, and Epstein-Barr viruses.

Approaches in Gene Therapy

Three general approaches have been used in the development of gene therapies, with adenoviruses showing effective promise in each approach.

  • Tumor-directed therapy. This is the introduction of a therapeutic gene (suicide gene) into tumor cells in an attempt to destroy them.
  • Active immunotherapy. Active immunotherapy is the administration of genes that will invoke the antitumor responses of the immune system.
  • Adoptive immunotherapy. Active immunotherapy is the administration of genetically altered lymphocytes that are programmed to cause tumor destruction.

Complementary and Alternative Medicine

Many patients seek a more holistic or nontraditional approach, turning to complementary and alternative therapies while continuing to utilize conventional medicine.

  • Complementary and Alternative Medicine (CAM). CAM was defined as diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.
  • Risk. Because of the possibility of herb-vitamin-drug interactions, there is concern about the use of biologicals and dietary supplements, which are not regulated by the FDA nor subjected to rigorous scientific evaluation.

Unproven and Unconventional Therapies

Hopelessness, desperation, unmet needs, lack of factual information, and family and social pressures are major factors that motivate patients to seek unconventional methods of treatment.

  • Definition. Unconventional treatments are those without scientific evidence of the ability to cure or control cancer.

Nursing Management in Unconventional Therapies

The most effective way to protect patients and families from fraudulent therapies and questionable cancer cures is to establish a trusting relationship, provide supportive care, and promote hope.

  • Communication. Truthful responses given in a nonjudgmental manner to questions and inquiries about unproven methods of cancer treatments may alleviate the fear and guilt on the part of the patient and the family that they are not “doing everything we can” to obtain a cure.
  • Information. The nurse should inform the patient and family should inform the patient and family of the characteristics common to fraudulent therapies so that they will be informed and cautious when evaluating other forms of “therapy”.
  • Collaboration. The nurse should encourage the patient to inform their physicians about the use of therapies to help prevent interactions with medications and other therapies that may be prescribed.

Nursing Care of Patients with Cancer


Main Article: 13 Cancer Nursing Care Plans

The outlook for patients with cancer has greatly improved because of scientific and technologic advances.

Maintaining Tissue Integrity

  • Stomatitis. Assessment of the patient’s subjective experience and an objective assessment of the oropharyngeal tissues and teeth are important and for the treatment of oral mucositis, Palifermin (Kepivance), a synthetic form of human keratinocyte growth factor, could be administered.
  • Radiation-associated skin impairment. Nursing care for patients with impaired skin reactions includes maintaining skin integrity, cleansing the skin, promoting comfort, reducing pain, preventing additional trauma, and preventing and managing infection.
  • Alopecia. Nurses provide information about hair loss and support the patient and family in coping with changes in body image.
  • Malignant skin lesions. Nursing care includes cleansing the skin, reducing superficial bacteria, controlling bleeding, reducing odor, protecting the skin from further trauma, and relieving pain.

Promoting Nutrition

  • Anorexia. Anorexia may occur because people feel full after eating only a small amount of food.
  • Malabsorption. Surgical intervention may change peristaltic patterns, later gastrointestinal secretions, and reduce the absorptive surfaces of the gastrointestinal mucosa, all leading to malabsorption.
  • Cachexia. Nurses assess patients who are at risk of altered nutritional intake so that appropriate measures may be instituted prior to nutritional decline.

Relieving Pain

  • Assessment. The nurse assesses the patient for the source and site of pain as well as those factors that increase the patient’s perception of pain.
  • Cancer pain algorithm. Various opioid and nonopioid medications may be combined with other medications to control pain as adapted from the World Health Organization three-step ladder approach.
  • Education. The nurse provides education and support to correct fears and misconceptions about opioid use.

Decreasing Fatigue

  • Assessment. The nurse assesses physiologic and psychological stressors that can contribute to fatigue and uses several assessment tools such as a simple visual analog scale to assess levels of fatigue.
  • Exercise. The role of exercise as a helpful intervention has been supported by several controlled trials.
  • Pharmacologic interventions. Occasionally pharmacologic interventions are utilized, including antidepressants for patients with depression, anxiolytics for those with anxiety, hypnotics for patients with sleep disturbances, and psychostimulants for some patients with advanced cancer or fatigue that does not respond to any medication.

Improving Body Image and Self-esteem

  • Assessment. The nurse identifies potential threats to the patient’s body image experience, and the nurse assesses the patient’s ability to cope with the many assaults to the body image experienced throughout the course of the disease and treatment.
  • Sexuality. Nurses who identify physiologic, psychologic or communication difficulties related to sexuality or sexual function are in a key position to help patients seek further specialized evaluation and intervention if necessary.

Assisting in the Grieving Process

  • Assessment. The nurse assesses the patient’s psychological and mental status, as well as the mood and emotional reaction to the results of diagnostic testing and prognosis.
  • Grieving. Grieving is a normal response to these fears and to actual or potential losses.

Monitoring and Managing Potential Complications

  • Infection. The nurse monitors laboratory studies to detect any early changes in WBC counts.
  • Septic shock. Neurologic assessments are carried out, fluid and electrolyte status is monitored, arterial blood gas values and pulse oximetry are monitored, and IV fluids, blood, and vasopressors are administered by the nurse.
  • Bleeding and hemorrhage. The nurse may administer  IL-11, which has been approved by the FDA to prevent severe thrombocytopenia, and additional medications may be prescribed to address bleeding due to disorders of coagulation.

Promoting Home and Community-Based Care

Nurses in the outpatient settings often have the responsibilities for patient teaching and for coordinating care in the home.

  • Teaching patients self-care. Follow-up visits and telephone calls from the nurse assist in identifying problems and are often reassuring, increasing the patient’s and the family’s comfort in dealing with complex and new aspects of care.
  • Continuing care. The responsibilities of the home care include assessing the home environment, suggesting modifications at home or in care to help the patient and the family address the patient’s physical needs.

Practice Quiz: Cancer


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1. The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?

A. Fresh fruit salad.
B. Orange sherbet.
C. Strawberry yogurt.
D. French fries.

1. Answer: C. Strawberry yogurt

  • C: Yogurt has high biologic value because of the protein and fat content.
  • A: Fruit salad does not have high amounts of protein or fat.
  • B: Orange sherbet is lower in fat and protein than yogurt.
  • D: French fries are high in calories from fat but low in protein.

2. After the nurse has explained the purpose of and schedule for chemotherapy to a 23-year-old patient who recently received a diagnosis of acute leukemia, the patient asks the nurse to repeat the information. Based on this assessment, which nursing diagnosis is most likely for the patient?

A. Acute confusion related to infiltration of leukemia cells into the central nervous system.
B. Knowledge deficit: chemotherapy related to a lack of interest in learning about treatment.
C. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis.
D. Risk for ineffective adherence to treatment related to denial of need for chemotherapy.

2. Answer: C. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis

  • C: The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information.
  • A: The patient’s history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion.
  • B&D: The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiologic factors.

3. A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the RN caring for the patient indicates that the nurse should take action?

A. The patient’s visitors bring in some fresh peaches from home.
B. The patient ambulates several times a day in the room.
C. The patient uses soap and shampoo to shower every other day.
D. The patient cleans with a warm washcloth after having a stool.

3. Answer: A. The patient’s visitors bring in some fresh peaches from home.

  • A: Fresh, thinned-skin peaches are not permitted in a neutropenic diet because of the risk of bacteria being present.
  • B: The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors.
  • C: Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable.
  • D: Careful cleaning after having a bowel movement will help to prevent perineal skin breakdown and infection.

4. While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse what the difference is between a benign tumor and a malignant tumor. The nurse explains that a benign tumor differs from a malignant tumor in that benign tumors

A. Do not cause damage to adjacent tissue.
B. Do not spread to other tissues and organs.
C. Are simply an overgrowth of normal cells.
D. Frequently recur in the same site.

4. Answer: B. do not spread to other tissues and organs.

  • B: The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize.
  • A: Both types of tumors may cause damage to adjacent tissues.
  • C: The cells differ from normal in both benign and malignant tumors.
  • D: Benign tumors usually do not recur.

5. A patient who smokes tells the nurse, “I want to have a yearly chest x-ray so that if I get cancer, it will be detected early.” Which response by the nurse is most appropriate?

A. “Chest x-rays do not detect cancer until tumors are already at least a half-inch in size.”
B. “Annual x-rays will increase your risk for cancer because of exposure to radiation.”
C. “Insurance companies do not authorize yearly x-rays just to detect early lung cancer.”
D. “Frequent x-rays damage the lungs and make them more susceptible to cancer.”

5. Answer: A. “Chest x-rays do not detect cancer until tumors are already at least a half-inch in size.”

  • A: A tumor must be at least 1 cm large before it is detectable by an x-ray and may already have metastasized by that time.
  • B: Radiographs have low doses of radiation, and an annual x-ray alone is not likely to increase lung cancer risk.
  • C: Insurance companies do not usually authorize x-rays for this purpose, but it would not be appropriate for the nurse to give this as the reason for not doing an x-ray.
  • D: A yearly x-ray is not a risk factor for lung cancer.

See Also


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Further Reading and Recommended Resources


Resources you make like:

  1. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
  2. Medical-Surgical Nursing: Assessment and Management of Clinical Problems
  3. Medical-Surgical Nursing: Patient-Centered Collaborative Care
  4. Saunders Comprehensive Review for the NCLEX-RN Examination
  5. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
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