N3 Exam 1, two compiled exams
1. The nurse realizes that for a cell to become cancer, it needs to progress through four stages. Which of the
following is not a stage of this process? Stimulation.
2. A client's tumor was staged using TNM system. The tumor was staged as T4, N1, Mx. The nurse realizes that this
stage means: Large tumor, single node involvement, unable to assess metastasis.
3. A client prescribed to begin chemotherapy, ask the nurse “How does chemotherapy work?” which of the
following should the nurse respond to this client? It prevents the process of cell growth and replication.
4. A client is prescribed interferon as part of treatment for cancer. Which of the following should the nurse instruct
the client regarding this medication? General fatigue while receiving this medication is common.
5. A client receiving chemotherapy for cancer has a hemoglobin level of 9.7g/dL. Which of the following should the
nurse anticipate as treatment for this client? Administer epoetin alfa as prescribed.
6. A client receiving chemotherapy has a platelet count of 85,000. Which of the following should the nurse do to
assist this client? Assess for bruising and flank bleeding.
7. A client is experiencing nausea and vomiting 1 day after chemotherapy has begun for cancer treatment. The nurse
realizes this client’s nausea and vomiting would be considered: Delayed.
8. Even though a client has completed a course of chemotherapy and has been found to be cancer free at this time,
she continues to experience fatigue. Which of the following should the nurse instruct this client? Fatigue can persist
after treatment ends, but it will eventually improve.
9. A nurse is teaching at a health fair about early warning signs of cancer. Which of the following would the nurse
include as early warning signs? (Select all that apply) (1) A sore that does not heal (2) Change in bladder and bowel
habits (3) Unusual discharge (4) Obvious change in Nevus (5) Nagging cough.
10. A client prescribed a selective estrogen receptor modulator as treatment for ovarian cancer. Which of the
following should the nurse instruct the client regarding side effects of this medication? (Select all that apply) (1)
Hot flashes (2) Blood clots (3) Reduce libido (4) Increased risk of developing other cancers.
11. After a Native American client has died, the family begins the practice of purifying the body. The nurse realizes
that the deceased client may stay with the family for what period of time? 36 hours.
12. The nurse is concerned that the spouse of a terminally ill client is experiencing Anticipatory Grieving when
which of the following is assessed? Expressing anger about the client’s pending death and crying throughout the
day.
13. A client is receiving care for symptoms; however, the treatment will not alter the course of the disease. This
client is receiving which type of care? Palliative
14. A client of the Hispanic culture is nearing death and the family requests that the client be prepared for discharge.
The nurse realizes that the reason why the family and client wants to return home is because: The spirit may get lost
if the client dies in the hospital, and will not be able to find his way home.
15. During the period of a time when a client diagnosed with a terminal illness became comatose, a health care
proxy made decisions about the client’s care. When the client regained consciousness a few days later, the nurse
consulted whom regarding the client ongoing care decisions? The client.
16. A terminally ill client is experiencing nausea. Which of the following interventions can be used to help the client
at this time? Administer diphenhydramine (Benadryl) as prescribed.
17. A terminally ill client is more alert and talkative, and she requesting specific foods to eat. The nurse should
caution the family regarding the client’s behavior because this could indicate: Final surprising rally before
retreating.
18. The nurse is concerned that a hospice client is approaching death when which of the following is assessed?
Restlessness, irritability, and anxiety.
19. The nurse is discussing end-of-life wishes with a client and his family. Since the client is not sure of what kind
of care he wants, the nurse provides the document “five wishes” because this document provides which of the
following types of information? (Select all that apply?) (1) What the client wants his loved ones to know (2) The
level of comfort that client wants (3) The person designated by the client to make health care decisions (4) The kinds
of medical treatment that the client wants or does not want (5) The way in which the client wants to be treated.
20. The nurse is making a home visit to a client receiving hospice care. Which of the following symptoms will the
nurse assess in the client during the visit? (Select all that apply) (2) Anxiety (3) Confusion (4) Depression
21. The nurse assess pain in a client receiving hospice care, uses the ABCDE model to guide pain management.
Which of the following is a part of this pain management approach? (Select all that apply?) (1) Ask about the pain
regularly (2) Believe the patient and family in their reports of pain (3) Enable the patient to control her course of
pain management to the greatest extent possible.
22. A client with terminal illness refuses pain medication. The nurse realizes that the patient may decline pain
medication for which of the following reasons? (1) Fear that the pain means disease is worse (2) Fear of becoming
addicted (3) Fear of side effects (4) Concern of being a bad patient.
23. A Client diagnosed with cancer. The nurse realizes that which of the following are characteristics of this type of
cancer cells? (1) Aneuploid (2) Migratory (3) Poorly differentiated (4) Abnormal chromosomes.
24. A client tells the nurse that her primary care physician is an osteopath. The nurse realizes that this physician will
utilize which of the following approaches when providing care to the client? (Select all that apply) (1) Surgery (2)
Manipulation (3) Medications
25. The nurse is planning to instruct a client on strategies to lessen the impact of lifestyle on the development of
cancer. Which of the following should the nurse include in these instructions? (Select all that apply) (1) Follow a
low-fat diet (2) Exercise regularly (3) Limit sun exposure (4) Do not smoke or use any tobacco products.
26. A client who is experiencing nausea and vomiting related to chemotherapy. Which of the following strategies
can the nurse use to improve nutrition in this client? (Select all that apply.) (1) Adding peppermint to the foods (2)
Administering ondansetron (3) Drinking adequate fluids (4) Eating foods at room temperature
27. A client tells the nurse that she utilizes biofeedback to combat chronic back pain. The nurse identifies this type
of complementary alternative medicine as being: Mind-body therapy.
28. A client’s most recent prostate-specific antigen levels has decreased since starting treatment for prostate cancer.
The nurse realizes this level would indicate that the client: Is responding to treatment.
29. The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep
and rapid breathing. The nurse document this finding as: Cheyne-Stokes respirations.
30. A client tells the nurse that his health has improved since he started practicing tai chi. The nurse realizes this
alternative medicine approach: Improves the flow of chi through the meridians of the body.
31. The nurse is providing a terminally ill client with morphine for pain control. In addition to this medication,
which of the following can be provided to enhance analgesic effect? (Select all that apply) (1) Antidepressant (2)
Anticonvulsant (3) Corticosteroid.
32. A client receiving chemotherapy tells the nurse that he is concerned that he may be developing Alzheimer’s
disease since he’s having a new onset of memory loss. Which of the following should the nurse do to help this
client? Suggest the client use a journal to aid with short-term chemo fog problems.
33. The nurse is planning interventions to address the potential problems of mucositis for a client receiving
chemotherapy. Which of the following assessment findings caused the nurse to identify the client as being at risk for
this side effect? Client prescribed chemotherapy.
34. The nurse would incorporate which of the following to the plan of care as a primary prevention strategy for
reduction of the risk for cancer? Using skin protection during sun exposure while at the beach.
35. When asked about an armband that a pregnant client is wearing, the client tells the nurse that it helps reduce
morning sickness. The nurse realizes this client is utilizing which form of alternative medicine? Acupressure
36. In caring for a client following lobectomy for lung cancer, which of the following should the nurse include in the
plan of care? Instruct the patient to cough and deep breath
37. A dying client is surrounded by family and friends at home. The hospice nurse talks with the spouse of the dying
client to ensure that everything the family needs during this time is being done. The nurse is providing support to:
The bereaved.
38. A client with terminal illness was ingesting morphine sulfate 10 mg by mouth every 6 hours for pain. To ensure
that the client receives the same degree of pain control when delivering the same medication through the intravenous
route, which of the following should the nurse do? Consult a standing order dose equivalent table to determine the
dose of morphine sulfate the client will need through the intravenous route.
39. A client tells the nurse that he believes watching old comedy movies has helped him achieve a quick recovery
from orthopedic surgery. The nurse realizes that this client has been using which of the following forms of
complementary alternative medicine? Humor.
40. While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most
appropriate nursing intervention? Prioritization and administration of nursing care throughout the day.
41. A client from the Asian culture tells the nurse that he has blockages in his life force that are causing him to have
a disease. The nurse realizes that within this culture, the life force is considered: Chi
42. A client tells the nurse that she is interested in learning yoga to help with chronic back pain and leg pain. Which
of the following should the nurse respond to this client? Local organizations have yoga classes and training
programs that you can attend.
43. The nurse is providing the client with a massage in other to create which of the following benefits? Reduce
blood pressure.
44. While collecting a health history on a patient admitted for colon cancer, which of the following questions would
be a priority to ask this patient? “Have you noticed any blood in your stool?”
45. After an assessment, the nurse believes that a client would benefit from the care of a chiropractor. Which of the
following health problems could be addressed with this form of alternative therapy? Headache
46. A client tells the nurse that she uses alternative forms of health care to help with her chronic health problems.
The nurse realizes that which of the following would be considered alternative forms of health care? (Select all that
apply) (1) Chiropractor (2) Massage (3) Yoga (4) Acupuncture.
47. A client recovering from bone marrow transplantation is experiencing vomiting, fatigue, and skin reactions.
Which of the following should the nurse do to help this client? Explain that the client is experiencing expected shortterm side effects.
48. A client asks the nurse what he can do to prevent the onset of cancer. The nurse realizes that which of the
following contribute to the development of cancer? (Select all that apply) (1) Lifestyle (2) Age (3) Environment (4)
Heredity
49. Which of the following statement made by a client after receiving instruction regarding internal radiation would
indicate that teaching has been successful? The hospital staff will limit the amount of time in my room.
50. A client tells the nurse that he ingests only herbal preparations and not medications prescribed from a physician.
Which of the following should the nurse respond to this client? “Are you aware of the side effects of using herbal
preparations?”
51. Which of the following statements made by a client after receiving instructions regarding internal radiation
would indicate that teaching has been successful? The hospital staff will limit the amount of time in my room
52. A cancer client’s blood test results are as follows: WBC 1,000, Hb 14g/dl, HCT 42%. Which goal would be
MOST important for this client? Prevent Infection
53. The client tells the nurse that even though it has been four months since her sister’s death, she frequently finds
herself crying uncontrollably. The client is afraid that she is “losing her mind”. What is the nurse's best response?
Your feelings are completely normal and may continue for a long time
54. A client presents with squamous cell carcinoma of the lung complains of shortness of breath, cyanosis and
edema of the face and arms. The nurse suspects which of the following complications? Superior Vena Cava
Syndrome
55. The Nursing Diagnosis for a client receiving external radiation to the left thorax to treat lung cancer has a
nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?
Avoid using soap on the irradiated areas or Clean the irradiated areas with water and/or mild soap
56. A client is anxious about having a dressing change. Which statement indicates that the nurse is promoting
appropriate complementary therapy? As we begin the next dressing change, I want you to think of a beautiful, calm
place where you feel happy and peaceful.
57. The unlicensed assistive Personnel (UAP) tells the nurse that the dying client is manifesting a death rattle.
Which action should the nurse perform? Instruct the UAP to initiate postmortem care
58. A nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse
anticipates including information about which medication? Filgrastim (Neupogen) or Tamoxifen (Nolvadex)
59. A nurse is caring for a terminally ill client who is unresponsive. The nurse correctly identifies the client's pain
and distress by observing which of the following? 1. Observes for respiratory signs 2. Observes for grimacing
3.Monitor vital signs
60. A terminally ill client begins to experience fatigue and weakness at the end of life. The nurse will provide which
of the following? 1. Place client on bedrest 2.Space out activities 3.Increase IV fluids 4. Insert a foley catheter to
avoid the need for exertion with voiding
61. (Check) A client is preparing for surgery and may not take any medications which will increase bleeding time.
The nurse reviews the client list of over the counter medications and instructs him to stop taking which of the
following? 1.Garlic 2. Ginger 3.Bilberry 4. Feverfew 5.Ginkkgo 6.Dong quai 7. Kava
62. What comfortable measures can only be performed by a nurse, as opposed to unlicensed assistive personnel
(UAP), for patient who returned from a left modified radical mastectomy 4 hours ago? Administering morphine for
pain at a 4 on a 0-to-10 scale
63. A nurse cares for a dying client. Which manifestation of dying does the nurse treat first? Pain
64. A patient on the medical surgical unit has a platelet count of 90,000 per mm3. The nurse knows to include which
of the following precautions in the discharge instructions? Use a soft bristled toothbrush
65. A nurse working with a client who experience alopecia knows that which is the best method of helping clients
manage the psychosocial impact of this problem? Assist the client to pre plan for this event
66. A hospitalized client who has a living will that states he doesn't want aggressive life saving measures is being
fed through a nasogastric tube. During a bolus feeding, the client vomits and begins choking. Which action is most
appropriate for the nurse to take? Clear the Client's airway
67. The nurse is being trained in hospice care. Which intervention by the nurse is most compatible with the goals of
end of life care for the client? Permit the client with diabetes mellitus to have a serving of ice cream.
68. A client receiving chemotherapy tells the nurse he is concerned he may be developing Alzheimer’s disease
because of recent memory loss. Which of the following should the nurse do to help this client? Provide resources for
cognitive training
69. A 35 year old woman is diagnosed with stage 3 breast cancer. She seems to be extremely anxious. What actions
by the nurse is best? Explore the idea of a referral to a breast cancer support group.
70. A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies does the nurse
incorporate into this client’s pain management plan? 1.Play music that the client enjoys 2.Rub lavender lotion on the
clients feet
71. The nurse is developing a plan of care for the client experiencing neutropenia secondary to chemotherapy. The
nurse plans to? Teach the client and family about the need for hand hygiene.
72. Mr. A. is admitted to the medical unit with magnesium deficiency. His physician orders a magnesium infusion.
Order: Magnesium to infuse at 225ml/hr via pump supply. It is available as Magnesium sulfate 3g in 250 mL. What
is the flow rate in mL/hr? I believe the final value should be written as 3g/mL or the question in accurate
225mL
3g
3g
hr
250mL
hr
.
73. For a client newly diagnosed with radiation induced thrombocytopenia, which intervention should the nurse
include in the plan of care? Inspect the skin for petechiae once per shift.
74.The intent of proportional palliative sedation is to achieve which end result? to manage refractory symptoms of
distress and promote comfort.
75.A client asks the nurse what he can do to prevent the onset of cancer. The nurse realizes which of the following
contribute to the development of cancer ? SATA. heredity, environment, lifestyle, diet, age.
76.During the period of time when a client diagnosed with terminal illness become comatose, a health care proxy
made decisions about the client’s care. When the client regains consciousness and is competent a few days later, the
nurse consults when regarding the clients ongoing care decisions? The client
77.a client prescribed to begin chemotherapy, asks the nurse, ‘’How does chemotherapy work?’’which of the
following should the nurse respond to this client?it prevents the process of cell growth and replication
78.A client's tumor was staged using the TNM system. The tumor was staged as Tis, N1, M0. the nurse realizes that
this staging means: Tumor in situ, minimal node involvement, no presence of metastasis.
79. While collecting a health history on a client admitted for colon cancer. Which of the following questions would
be a priority to ask this client? Have you noticed any blood in your stool?
80. After cancer chemotherapy, a client develops nausea and vomiting. For this client, the nausea should give the
highest priority to action in the plan of care? Serving small portions of bland food
81. Care of the client with a brain tumor includes which one of the following interventions? Monitor I & O and
specific gravity to detect the onset of syndrome of inappropriate ADHD (SIADH)
82. A nurse caring For a terminally ill client is aware of impending death when which of theses signs and symptoms
occur? SATA. incontinence, slowing of the circulation, agonal respiration, mottling of skin.
83. A terminally ill client is experiencing restlessness. Which interventions can the nurse provide to comfort this
client? Play soothing music.
84. The nurse is planning interventions to address the potential problem of mucositis for a client receiving
chemotherapy. Which of the following assessment findings caused the nurse to identify as being at risk for this side
effect? A client receiving chemotherapy.
85(40) why does the nurse wear a dosimeter when providing care to the patient receiving brachytherapy? Determine
the amount of radiation exposure experienced.
86. Which patient scenario describes the best example of professional collaboration? The nurse and physician
discuss the patients muscle weakness and initial a referral for physical therapy.
87. The nurse cares for a terminally ill client who is experiencing cheyne stokes respirations. Which action by the
nurse would be most appropriate? provide comfort measures.
88. A nurse is providing education to a community group about the benefits of massage. The nurse evaluates that the
education was successful when the community member state which of the following are the benefits of massage
therapy? SATA. Relaxes muscles, improves blood and lymph flow, reduces anxiety, relieve pain.
89. In which oncology stage does a tumor develops its own blood supply? progression
90. A terminally ill client is more alert and talkative, and she is requesting specific foods to eat. The nurse should
caution family regarding the client’s behavior because this could indicate: A final surprising rally.
91. A client with nausea and vomiting wants to know if there’s an alternative to prescription medications. The nurse
correctly identifies which supplement? ginger
92. A client is experiencing dyspnea in their last moments of life Which intervention will the nurse provide?
morphine
93. After teaching a client about advance directives, a nurse assesses the client’s understanding. Which statement
indicates that the client correctly understand the teaching? An advance directive will specify what I want done when
i can no longer make decisions about health care.
94 Mr. O. is admitted to the ICU with cardiac decompensation. His physician orders a Dobutamine drip via infusion
pump. Order: Dobutamine iv to infuse at 8mcg/kg/min. Supply. It is available as Dobutamine 175mg in 200mL. Mr.
O. weighs 95kg. What is the flow rate in mL/hr? 52mL/hr
N3 Exam 1 from 2016 (They used some from this exam last quarter)
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A nurse is caring for a terminally ill client who is unresponsive; the nurse correctly identifies the client’s
pain and distress by which of the following? Observes for respiratory signs, Observes for grimacing,
Monitor vital signs
A nurse is assessing a client’s skin care after external radiation therapy, the nurse documents the client
verbalizes understanding of skin care after the client states which of the following? Massage the area to
increase circulation, The radiation marking tattoo should be washed off with mild soap and water, I can use
my OTC cream with the skin that is radiated, Avoid direct sunlight
A nurse is caring for a restless client with diabetes; the client has metastatic cancer and has 6 months to
live. During morning rounds the client requests a chocolate shake. The nurse correctly responds. I will call
the kitchen and see if they have some
The nurse cares for a dying client, what manifestations of dying does the nurse treat first?
Pain
A licensed practical/vocational nurse has been ordered to the hospice unit. The charge nurse may delegate
to the LPN/LVN? Encourage family members to talk, Determine how often physical assessments are
needed, Teach family members about commonly occurring signs of approaching death, Administer
morphine for pain control
A client with recent chemo tells the nurse he is concerned he may be developing Alzheimer’s because of
recent memory loss. Which of the following should the nurse do to help the client? Keeping a journal
Family members at the bedside of a terminally ill client are concerned with the onset of loud wet
respirations. Which intervention will the nurse provide for the death rattle? Atropine
A nurse is providing a terminally ill client with morphine for pain control. In addition to the medication
which of the following adjuvants can be prescribed? Anticonvulsants, Corticosteroids, Antidepressants
When caring for a client with tumor lysis the nurse administers glucose and insulin for which condition?
Hyperkalemia
While planning care for a client experiencing fatigue due to chemotherapy. Which of the following is the
most appropriate nursing intervention? Space out activities throughout the day
A client receiving chemotherapy for cancer has a hgb of 9.7. which of the following should the nurse
anticipate as treatment for the client? Administer epoetin
A nurse is caring for a terminally ill client who has just died in the hospital and the family is by the bedside.
What will the nurse do first? Call for the doctor to rule clinical death, Allow family members to spend time
with the patient
A clients tumor is stage using the TNM system T4N3M1. Large tumor, multiple nodes and presence of
metastasis
A client with cancer is admitted to a short-term rehab facility. The nurse prepares to administer the client’s
chemo medicine. Which action by the nurse is most appropriate? Wear personal protective equipment
A nurse is planning interventions to address the potential problem of mucositis for a client receiving
chemo. Which of the following interventions by the nurse? Administer something for the lips I chose
A nurse caring for a terminally ill client is aware of impending death when which of the following occur?
Fixed pupils, Slowing of circulation, Irregular respirations, Mottling of the skin
A client presents with squamous carcinoma of the lung complains of SOB, cyanosis, edema of the face and
arms. Superior vena cava syndrome
A terminally ill client begins to experience fatigue and weakness at the end of life. The nurse will provide
which of the following? Place client on bedrest, Space out activities, Increase IV fluids
19. A dying client is surrounded by family and friends at home, the hospice nurse talks with the spouse of the
dying client to ensure that everything the family needs is being done. The nurse is providing support to.
The bereaved
20. When asked about an armband that a pregnant client is wearing. The client states it helps with morning
sickness. The nurse realizes the client is utilizing which form of alternative medicine? Acupressure
21. A terminally ill client is more alert and talkative. She is requesting specific foods to eat. The nurse should
question the family regarding the family’s behavior because this can indicate? Final surprising rally before
retreating
22. The nurse would incorporate which of the following into the plan of care as a secondary strategy as
prevention? Colonoscopy at 50 and 10 years
23. A nurse is caring for a terminally ill client who has 20 second periods of apnea followed by periods of deep
rapid breathing. Cheyne stokes respirations
24. The nurse cares for a terminally ill client who is experiencing cheyne stoke respirations. Which action by
the nurse is most appropriate? Place the client in a high fowler position, Place O2, Provide comfort
measures
25. A nurse working with a client who experience alopecia knows that which is the best method of helping
clients manage the psychosocial impact of this problem? Assist the client to pre plan for this event,
Teaching the client ways to protect the scalp
26. A nurse is instructing a client on strategies to lessen the impact on lifestyle on the development of cancer.
Limit sun exposure, Exercise regularly, Do not smoke or any tobacco, Follow a low fat diet
27. A client prescribed to begin chemotherapy asks the nurse how does chemotherapy work? Which of the
following should the nurse respond? Systemic and targets rapidly dividing cells
28. Order 175mg/250 ml. 7mcg/kg/min. pat weighs 121 kg. What is ml/hr? 73ml/hr
29. A client with prostate cancer is receiving chemotherapy. The client develops Thrombocytopenia. What is
the highest priority? Assess for bleeding
30. A client is experiencing dyspnea in the last moments of life. Which intervention will the nurse provide?
Morphine
31. A client is prescribed a selective estrogen receptor modulator. Which of the following is a side effect of this
medication? Hot flashes, Blood clots, Reduced libido
32. A client is diagnosed with metastatic cancer. The family asks the nurse what is the difference between
hospice and palliative care? The nurse correctly responds with which statement? Palliative care is for
clients in any stage of serious illness
33. A nurse assesses a client who is dying. Which manifestations does the nurse determine whether the client is
near death? Respiratory rate
34. A client receiving chemotherapy has a platelet count of 45000. Assess for bleeding and bruising
35. A nurse is providing community education on the signs of cancer. All of the following are signs of cancer
except? Which one is NOT. (CAUTION) Daily abdominal pain
36. Which carcinogen stage does invasion and damage the DNA occur and not reversible? Initiation
37. A client is experiencing nausea after 2 days after receiving chemotherapy. The nurse realizes the client’s
nausea is related to? Delayed
38. A competent terminally ill client no longer wishes to eat or drink in order to hasten death. The client is
exercising which end of life concept? Terminal dehydration
39. After teaching the client about advance directives teaching? Advance directive will specify what I want
done when I am no longer able to make decisions about my care
40. Which of the following patients is a candidate client for hospice care? Colon cancer client with 6 months to
live
41. Native American dies and stays with family for how long? 36 hours
42. A terminally ill client is experiencing restlessness. Which interventions will the nurse to provide for
comfort of the client? Soothing music
43. The nurse is providing the client with massage in order to create the following benefits? Reduce BP
44. A nurse caring for oncology patient knows that which of following metastasis is the most common?
Bloodborne
45. Cancer cells exhibit which of the following features? Migration
46. Practitioner orders Morphine 3mg. have 7 mg what is mL? 0.42 mL
47. A client is experiencing nausea and vomiting related to chemotherapy the nurse would use which of the
following interventions? Administer Zofran, Eat food at room temp, Consume flood with electrolytes and
glucose during times of emesis
48. Your client is admitted to the ICU with MI. the physician orders infusion rate. 2 mL
49. A nurse is caring for several children with cancer and is reviewing their morning lab results. Which of the
client condition combined with an indicated lab results cause the most concern? Fever with Neutrophil 450
mm
50. A client is receiving care to manage their symptoms. This will not alter the course of the disease. What type
of care? Palliative
Exam 1 NOTES
Mod 1: Ch 21-22 Med-Surg Nursing
Chapter 21
Cancer – Pathophysiology
Cellular regulation: process to control cellular growth, replication, and differentiation to maintain
homeostasis
o
All steps are the result of gene interactions
o
They only reproduce if needed.
Differentiation: maturing into a specific cell type
Neoplasia: any new or continued cell growth not needed for normal development or replacement of dead
and damaged tissues
o
Abnormal even if benign
Biology of Normal Cells
Specific morphology: each normal cell type has a distinct and recognizable appearance, size, and shape
Smaller nuclear-to-cytoplasmic ratio: nucleus of normal cell occupies a small amt of space inside the cell
Differentiated function: every normal cell has at least 1 function it performs to contribute to whole body
function
o
Example: liver cells make bile
Tight adherence: occurs because normal cells make proteins that protrude from the membranes, allowing
cells to bind closely and tightly together.
o
Example: one protein is fibronectin.
o
EXCEPTIONS are RBC and WBC
Nonmigratory: normal cells do not wander throughout the body (except for blood cells). Occurs because
they are tightly bound together
Orderly and well-regulated growth: or cellular regulation.
o
They undergo mitosis to develop normal tissue OR to replace lost/damage tissue.
o
Divide only when body conditions are just right
o
Mitosis: cell division
Steps are tightly controlled
Contact inhibition: cellular regulation that stops further rounds of cell division when the dividing cell is
completely surrounded and touched by other cells
o
Mitosis does NOT occur when cells are completely in contact with surrounding cells. It will stop
replicating then.
Apoptosis: programmed cell death.
o
Euploidy: having a complete set of chromosomes
23 pairs is normal
Biology of Abnormal Cells
Benign Tumor Cells
Normal cells growing in the wrong place or at the wrong time as a result of a problem with cellular
regulation.
o
Moles, uterine fibroid tumors, skin tags, nasal polyps
See table above for differences and properties
Cancer Cells
Anaplastic: loss of the specific appearance of their parent cells.
Cell nucleus is larger than that of a normal cell, and the cancer cell itself is smaller
They serve no useful purpose in the body
They metastasis: spread to other areas of the body
They continue to divide (go through mitosis) even when all surfaces of the cells are in contact with other
surrounding cells.
They have an unlimited life span, not finite like normal cells
Aneuploidy: chromosome structure and number not 23 (normal). Happens because they become more
malignant.
Carcinogenesis and Oncogenesis are other names for cancer development.
Malignant transformation: process of changing a normal cell to a cancer cell
Steps in Carcinogenesis:
1.
Initiation: genes promote cell division and produce more cyclins.
a.
Leading to a loss of cellular regulation
b.
Widespread metastatic disease can develop from just ONE cancer cell
c.
Carcinogens: substances that change the activity of a cell’s genes so that the cell becomes a cancer cell
2.
Promotion: enhanced growth of an initiated cell by substances (promoters).
a.
Cell can become a tumor if the growth is enhanced
b.
Latency period: time between when a cell is initiated and the growth of an overt tumor
i.
Can range from months to years
ii.
Exposure to promoters shortens this period
3.
Progression: continued change of cancer, making it more malignant over time.
a.
1 cm tumor = 1 billion cells
i.
TO BECOME A HEALTH CONCERN, it goes through angiogenesis: tumor develops its own blood
supply
b.
Tumor develops differences, providing it with advantages to live and divide no matter the surrounding
conditions in the body
c.
Primary tumor: original tumor
d.
Secondary tumor: or metastatic tumors. The cancer establishes remote colonies in other parts of the body
i.
If breast cancer spreads to the bone, it is called “breast cancer in the bone”, NOT “bone cancer”.
4.
Bloodborne Metastasis: most common cause of cancer spread
i.
Tumor cells are released into the bloodstream
ii.
Cancer cells penetrate the blood vessels
iii.
Tumor cells are only loosely held together, making it easy to break off and transport around to other areas
of the body
Tumor Classification
Grading: classifies cellular aspects of the tumor
Ploidy: classifies the number and structure of tumor chromosomes as normal or abnormal
Staging: classifies clinical aspects of cancer
Tumor, Node, Metastasis (TNM): system is used to describe the anatomic extent of cancer.
NOT useful for leukemia or lymphomas
Doubling time: amount of time it takes a tumor to double in size
Mitotic index: percentage of actively dividing cells within a tumor
Cancer Etiology and Genetic Risk
Oncogene activation: main mechanism of carcinogenesis regardless of specific cause.
o
Oncogenes are not abnormal; they are a part of every cell’s normal make up.
o
Only become an issue if they are over-expressed as a result to exposure of carcinogenic agents or loss of
cellular regulation
Immunity/age affects whether an adult is likely to develop cancer
o
Advancing age is the single MOST IMPORTANT risk factor for cancer
Primary Prevention of Cancer:
Avoid known potential carcinogens
Modifying associating factors
Removal of at risk tissues
Chemoprevention
Vaccination (HPV Hep B)
Secondary Prevention (early detection):
Mammograms
o
Every year after age 40
Colonoscopies
o
Every 10 years after age 50
Breast exams
Pap smears
Digital rectal exam (DRE)
o
Males, every year after age 50
Fecal occult blood test
o
Once per year, everybody
Tertiary
o
o
o
Treatment of the cancer
Chemo
Radiation
Surgery
Chapter 22
68% of people diagnosed with cancer are cured, and thousands live 5+ years.
Impaired Immunity and Clotting
Occurs when cancer invades the bone marrow where blood cells are formed
Patients at risk for infection
Thrombocytopenia (decreased number of platelets) results in impaired clotting
Anemia: fatigue, SOB, tachycardia
Altered GI Function
Increase metabolic rate and need for nutrients
o
Weight loss
o
Cachexia: extreme body wasting and malnutrition
May obstruct GI tract, reducing absorption or elimination ability
o
Avoid bowel obstruction
Liver damage can also lead to malnutrition
Altered Peripheral Nerve Function
Chemotherapy
o
Injured nerves, leading to reduced sensory perception
Loss of sensation in lower extremities
Numbness, tingling, neuropathic pain, changes in gait
Motor and Sensory Deficits
Cancer invades bone or brain or compress nerves
Bones become thinner, causing fracture risk, pain, spinal cord compression, and hypercalcemia
Cancer pain
May be chronic or acute
Managed by a team of your healthcare providers
Patient education regarding management and constipation
Altered Respiratory and Cardiac Function
Cancer can disrupt RR, and gas exchange
Can cause obstruction in airways if tumor grows there
Lung cancer leads to decreased lung capacity
Tumors can press on blood and lymph vessels in chest
Radiation and certain Chemo can affect cardiac function as well.
Cancer Management
Surgery
Prophylactic: removed potentially cancerous tissue as a means of preventing cancer development
o
Ex. Removing a colon polyp
Diagnostic: removal of all or part of a suspected lesion for examination and testing to rule out or confirm a
cancer diagnosis
Cancer control or Cytoreductive Surgery: removes part of a tumor when removal of entire mass is not
possible.
o
Aka Debulking
o
Decreases size of tumor and number of cancer cells within tumor
Palliative: focus is providing symptom relief and improving the quality of life
o
Is not curative
Reconstructive or Rehabilitative: increases function, enhances appearance, or both
*** Side effects of surgery:
Function reduction
Pain
Profound changes in activity or appearance
Radiation Therapy
Aka Radiotherapy
Used to kill cancer cells, provide disease control, or relieve symptoms
Is a local treatment because tissues ONLY in the radiation field are effected
Has both short and long term effects
o
Exposure: amount of radiation delivered to a tissue
o
Radiation dose: amount of radiation absorbed by the tissue
o
o
•
beams
•
•
o
•
•
•
•
•
•
NOTE: Dose is always LESS than the exposure because some energy will be lost
Gray (Gy): absorbed radiation doses are described in “gray” units
1 Gy = 1 joule of energy absorbed by 1 kg of material
Delivery methods and Devices
External Beam or Teletherapy: delivered from a source outside of the patient.
Patient is not radioactive, therefore not a hazard to others
Intensity-modulated radiation therapy - IMRT
Reduces normal tissue exposed to radiation by breaking up the single beam into thousands of smaller
Stereotactic body radiotherapy – SBRT
Uses 3D tumor imaging to identify exact tumor location
Precise radiation dose given to precise spot
Brachytherapy: internal radiotherapy (short (close) therapy)
Direct, continuous contact with tumor for specific time period
IV, oral, implantation
Higher dose of radiation
Source is within the patient, therefore they are radioactive and a hazard to others.
Nursing care for these patients:
Keep linens in their room until source is removed. Then discard as normal
Limit visitors to ½ hour per day. Nobody younger than 16
No pregnant women allowed to care for them
Do not care for them if attempting to conceive, both male or female
Lead apron on at all times
Xerostomia: dry mouth
Caused by head/neck radiation
Chemotherapy
Neoadjuvant chemotherapy: chemo is used to shrink a tumor before surgery or radiation
Adjuvant chemotherapy: used after surgery or radiation to kill remaining cancer cells
Alkylating agents: cross-link DNA, making the DNA strands bind closely together
Inhibits cell division
Antimetabolites: similar to normal metabolites
Act as “counterfeit” that fool cancer cells into using them in cellular reactions
Impairs cell division
Antimitotic agents: aka mitosis inhibitors
Interfere with formation and actions of microtubules, so cells cannot complete mitosis
Topoisomerase inhibitors: disrupt an enzyme essential for DNA synthesis and cell division
Results in cell death
Miscellaneous: drugs with mechanisms of action that are either unknown or do not fit these other categories.
Combination chemotherapy: using more than one type of chemo
Usually most effective
Different mechanisms of action
Side effects and damage to good tissues increase with combo therapy
Dose-dense chemo: giving doses close together, supplemented with bone marrow growth factors to prevent
neutropenia.
More intense side effects
Extravasation: occurs when IV chemo leaks into surrounding tissues from IV (infiltrates).
When the drugs are Vesicants (chemicals that damage tissue on direct contact), the results are very painful,
infected, and include tissue loss.
o
Surgery can be needed for severe damage
o
ALWAYS carefully monitor IV site and check for patency/blood return
Oral agents must NOT be crushed, broken, split, or chewed.
Side effects of Chemo:
Neutropenia: decreased number of neutrophil white blood cells, leading to immunosuppression
Alopecia: hair loss
Mucositis: open sores on mucous membranes
Can develop throughout the entire length of the GI tract
Anxiety, sleep disturbance, changes in cognitive function, altered bowel elimination
** The impact of these side effects is referred to as Cancer Therapy System Distress, which varies from patient to
patient.
Delegating cares to UAP or PCA:
Teach them importance of protecting patient from infection d/t immunosuppression
Mouth care, axillary, and perianal washing every 12 hours, no matter what.
Use a lift sheet when moving patient in bed
Use electric shaver, not a razor.
Chemotherapy-Induced Nausea and Vomiting (CINV).
Anticipatory: thinking about it, sight, smell
Acute: within 24 hours after treatment
o
Most common type
o
Persists for 1-2 days after chemo is given
Delayed: occurring after the first 24 hours
Breakthrough: occurring randomly throughout
Combination of multiple types
Antiemetics are given before, during, and after chemo to help.
They work best when given BEFORE the n/v begins.
Photodynamic Therapy
Selective destruction of cancer cells through a chemical reaction triggered by high energy laser light.
A drug that sensitizes to light is given IV along with a dye
48-72 hrs later, most of the drug is collected in high concentrations of cancer cells
Laser light is then focused on the tumor
Hormonal Manipulation: changing the body’s usual hormone response.
Affects cellular regulation by preventing the cancer cells from receiving normal hormonal growth
stimulation
Is not a cure
Side effects
o
Chest and facial hair on women
o
Menses stop
o
Breast tissue shrinks
o
Fluid retention
o
Acne
o
Hypercalcemia
Oncologic Emergencies
Sepsis
Abnormal clotting (Disseminated intravascular coagulation – DIC)
Spinal cord compression
Spinal Cord Compression:
Back pain, nerve deficits, weakness, loss of sensation, urinary retention, constipation, loss of deep tendon
reflexes
MRI
Corticosteroids
Radiation (high dose)
Surgery
Hypercalcemia
Cancer can secrete parathyroid hormone, causing bones to release calcium.
Dehydration worsens it
Skeletal pain, kidney stones, abdominal discomfort, AMS, lethargy, coma, n/v, increased urine output
ECG
IV hydration 500mL/hour
Loop diuretics
Superior Vena Cava Syndrome (SVCS)
Compression or obstruction caused by tumor growth or clots in vessel
Symptoms are more apparent in supine position
o
Edema of the face, tightness of collar, engorged blood vessels of upper body
Often associated with late stage disease and says that tumor is widespread
CT and MRI
Radiation therapy (high dose)
Chemo
Surgery is rarely performed.
Tumor Lysis Syndrome
Large numbers of tumor cells are destroyed rapidly
They are released into the bloodstream faster than the body can eliminate them
Positive sign that treatment is effective in destroying cancer cells
However, can cause kidney injury, tissue damage, and death.
Hydration, diluting K+ levels, increasing kidney flow rates, patient should be drinking tons of fluid (35,000mL per day), monitor weight and electrolyte values
CAM. Ch 29, NCLEX Review book AND Vocab Words
CAM: Practices or products that are not part of standard medical care such as massage, acupuncture, tai chi, or
essential oils.
5 CATEGORIES OF CAM
•
Mind-body
o
Biofeedback: Using your own thoughts/imagination to promote mental and physical health; ease stress,
pain, and anxiety.
o
Guided Imagery: Use of auditory and imaginary processes to help calm and relax patients; it’s more
effective for chronic pain versus acute pain
o
Intercessory prayer: A group of people use prayer to help someone’s needs.
o
Meditation: Focusing only on what you can control and the present.
o
Relaxation Exercises: Breathing, reading, yoga, etc.
•
Biologically based
o
Herbal Medicine: Use of plants or herbs to treat various disorders
Teach side effects and interactions
o
Vitamin and dietary supplements
•
Manipulative and body-based
o
Acupuncture: Fine needles inserted into the body at specific points to cure disease or ease pain.
o
Acupressure: Pushes on specific points with hands/fingers to relieve stress, pressure, nausea, etc.
o
Chiropractic therapy: Specific manipulation of spine or bones; helps with bone issues, pain, and headache.
o
Massage therapy
o
Shiatsu: Combo of massage, acupressure, stretching, and joint manipulation = means finger pressure.
o
Rolfing: Deep tissue massage to help with posture
o
Tai Chi: Moving meditation to improve chi, balance mind, body, and spirit
o
Yoga
•
Energy
o
Reiki: Transfers energy from therapist to patient
o
Therapeutic touch: Hands hover over the body, no touching.
•
Alternative medical systems
o
Osteopathy: Uses manual readjustments and physical manipulation of tissue and bones as an alternative
treatment.
o
Naturopathy: Alternative treatment that promotes healthy lifestyle, foods, exercise, and herbal medicine.
Supports health
o
Homeopathy: Stimulates the immune system and natural healing through plant, animal, and mineral
products.
Tao: Chinese philosophy in which people live a simple life in harmony and nature. (Chi = energy, belief
that if chi is disrupted then it is the cause of disease)
Nadir: Indicates the lowest point
Neoadjuvant: Treatment used to shrink the tumor before surgery, such as chemotherapy, targeted radiation
therapy, or hormone therapy.
Neoplasm: New growth (tumor)
Oncogene: A gene that has the potential to cause cancer.
Staging: Classifying tumors by how far the disease has progressed.
Stomatitis: Swelling and sores inside the mouth.
Tumor markers: Found in blood, urine, and body tissues that are elevated by the presence of one and more
types of cancer and used as an indicator for cancer.
Tumor Suppressor Gene: Normal genes that control cell growth and division.
Vesicant: An agent that causes blistering; most chemotherapeutic agents are vesicants
Adjuvant: Pharmacological/immunological agent that increases the effect other agents.
o
Ex: Vistaril increases strength of Oxycodone.
Allogeneic: Bone marrow/stem cell transplant using donation from genetically similar, but not identical
donor.
Alopecia: Hair loss
Angiogenesis: Process in which new blood vessels are formed.
Antineoplastic: Medication that prevents the growth or spread of malignant cells. Ex: Tamoxifen
Autologous: Using the patient’s own blood-forming stem cells
Brachytherapy:The use of internal isotopes that are implanted near the tumor which emits continuous
radiation to tumors or administered within body fluids orally or IV.
Cachexia: Wasting syndrome is loss of weight, muscle atrophy, fatigue, and weakness – general state of
illness.
Erythropoietic: Process which produces RBCs.
Glossitis: Inflammation of tongue
Grading: Tumor classification by cellular change.
-
Harvesting: Removal of cells, tissue, or organs for transplantation or experimentation
Hematopoietic: the formation of blood
Hyperplasia: Increased number of cells within an organ or tissue
Hypertrophy: Increase in size
Intrathecal : A route of administration that injects into the spinal canal or subarachnoid space to reach CSF.
Leukapheresis: Removal of WBC
Myelosuppression: Bone marrow activity is decreased resulting in less RBC, WBC, and platelets
Mod 2
Different Cultures and what to consider
Native Americans
No eye contact
May stay with their dead loved ones for up to 36 hours
African Americans
Bad luck to die in the home
Professionals to prepare the body
Independent
Home remedies are common
Chinese Americans
Family to prefer to deliver terminal illness news to their loved one (the patient), not MD
Eldest male tends to be decision maker
Acupuncture, herbs (eastern medicine)
Spirit gets lost if they die outside of the home
Japanese Americans
Family oriented; also eldest male is decision maker
DNR is decided by the entire family
Prefer to die at home
Hispanics
Prefer to take care of their families themselves
Eldest child (no matter the gender) is the decision maker
Try to stay positive because negativity hastens death
If you die outside the home, your spirit will get lost
Chapter 7 (Med-Surg Book)
Bad death: death without dignity
Good death: peaceful and meaningful
Peaceful death: one that is free from avoidable distress and suffering for patients and families, in agreement
with all wishes, and consistent with clinical practice standards
Leading causes of death:
Heart disease
Cancer (malignant)
Chronic lower respiratory disease
Accidents (intentional injuries)
Stroke, Alzheimer’s
Diabetes, Flu/pneumonia, kidney disease, suicide
SUPPORT: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment
Showed more than 50% of people with a life-threatening disease had moderate to severe pain in the last
days of their lives before death
They did not have their well-known wishes met
After this study, progress has been made
Pathophysiology of Dying
Death: cessation of integrated tissue and organ function, manifested by lack of heartbeat, absence of spontaneous
respirations, or irreversible brain dysfunction.
Inadequate perfusion to body tissues lack of O2 in cells anaerobic metabolism with acidosis, hyperkalemia, and
tissue ischemia
1` multiple organ dysfunction syndromes
Dramatic changes in vital organs lead to release of toxic metabolites and destructive enzymes
Occurs with renal and liver failure
o
Can also start the dying process
Comfort concept
PSDA: Patient Self Determination Act
Granted Americans the right to determine the medical care they wanted if they became incapacitated
1991 passed by US Congress
AD: Advance directive
The document that states what you’d like to be done
Power of Attorney: needs to be there to carry out all cares
Can overturn already made decisions by patient, so choose wisely
DPOAHC: Durable power of attorney for health care
Section within an AD
Often referred to as “health care proxy” or “surrogate decision maker”
Does not make decisions until a physician states that the person lacks capacity to make his or her own
health care decisions
Five Wishes Document
Person to make decisions when I can't
Type of medical treatment I do or don’t want
How comfortable I want to be
What I want my loved ones to know
How I want people to treat me
To have decision making ability, they must be able to:
1.
Receive information, but not necessarily be totally oriented
2.
Evaluate, deliberate, and mentally manipulate information
3.
Communicate a treatment preference
** Comatose patients do not have this ability.
LW: Living will (notarized, very official)
Identifies what one would or would not want if they were near death
Ex. CPR, vent, artificial nutrition
DNR: Do not resuscitate
Signed by a physician and patient
Intended for life-limiting conditions
By law, all primary health care professionals must initiate CPR unless that person has a DNR order.
CPR can be violent, preventing a peaceful death
May be unsuccessful, resulting in a more compromised patient than they were before
Hospice and Palliative Care
Hospice: quality, compassionate care for people facing a life-limiting illness or injury.
Team oriented
Support also given to patient’s loved ones
Homes, assisted living, prisons
Medicare Hospice Benefit: pays for hospice services if Medicare recipient has a prognosis of 6 months or less, and
who agree to forego curative treatment.
Palliative Care: philosophy of care for people with life-threatening disease that helps patients and families identify
their outcomes for care, assists them with decision making, and facilitates quality system management
Signs/Symptoms of near death:
Skin becomes mottled or discolored
o
Circulation to extremities is decreased
Keep patient warm
Increased sleeping
o
Metabolism is decreased
Spend quiet time sitting with the patient
Do not force them to stay awake with you
Talk to them as you normally would
Fluid/food decrease
o
Metabolic needs have decreased
No not force them to eat or drink
Offer small sips of liquids or ice chips
Mouth swabs
Lip balm
Incontinence
o
Perineal muscles relax
Keep clean and dry
Foley cath
Congestion and Gurgling
o
Unable to cough
Position patient on side, suction gently
Give meds to reduce secretion amount
Breathing pattern change
o
Slowed circulation to brain causes breathing pattern to become irregular
Elevate head, place on their side
Cheyne-Stokes Breathing is common: periods of apnea followed by rapid shallow breathing
Disorientation
o
Slowed circulation to brain
Introduce yourself, reorient
Restlessness
Soothing music
Aromatherapy
Do not restrain
Talk quiet, keep room dimly lit, consider sedation
Stages of Grief
Denial
Anger
Bargaining
Depression
Acceptance or resignation
Anticipatory grief: grieving before it happens
Assessing a patient’s spirituality at end of life:
H: Sources of hope and strength
O: Organized religion (if any) that plays a role in their life
P Personal spirituality, rituals, practices
E: Effects of religion and spirituality on care/end of life decisions
Bereavement: grief counselor
Hospital ER’s often have “bereavement rooms” where families can go to speak to the doctor, talk to
chaplain or counselor, and wait for news
Physical grief: physical signs that you’re grieving
Confusion, fatigue, can’t think clearly, emotionally drained
Emotional Signs of impending death:
Withdrawal: they are preparing to “let go”
Vision like experiences: Hallucinations
o
Affirm the experience, do not correct them
Letting go: agitation or repetitive tasks
o
Something may be unresolved to them, preventing them from letting go
o
Say things like “it’s okay, you can go. We will be okay. Everything’s okay.”
Saying goodbye: Verbalize your emotions to the dying person, it gives confirmation that everything will be
okay, and they will be missed
** Pain is the symptom that dying patients fear the most.
Nonpharmacologic Interventions:
Massage
o
Light pressure
Music Therapy
Therapeutic touch
Aromatherapy
o
Promotes relaxation and reduces anxiety
For end of life patients experiencing delirium:
Giving morphine can exacerbate it
o
Inability of failing kidneys to excrete morphine metabolites from the body
Give Fentanyl instead
o
No metabolites in it
o
Given to patients with renal failure
Oxycodone is also better than morphine
To treat dyspnea near death: Morphine Sulfate
Also
o
Bronchodilators
o
Corticosteroids
o
O2 ONLY if meds don’t work ...not a standard practice
o
Diuretics
o
Antibiotics for respiratory infections
o
Anticholinergics
Death rattle: loud, wet respirations
Proportionate palliative sedation: giving patients benzos, barbiturates, or anesthetic agents to lower sedation to
lessen suffering
Intent is to promote comfort, NOT hasten death
Active Euthanasia: hastening death (making it go faster)
Process of ending one’s life.
Not supported by the ANA
Physician assisted suicide (PAS): assisted dying by a physician
Gaining worldwide public support
Only 4 states are legal
Passive Euthanasia: withholding life sustaining therapy
“letting the person die naturally”
Does not directly cause the patient’s death.
Double Effect: Increasing the dose of the medication to achieve symptom control, even if it hastens death
VSED: voluntary stopping of eating and drinking
Terminal dehydration
Patients choose to do this