LEUKEMIA

PRE-TEST

1. A type of leukemia that results from the defect on the differentiation of hematopoietic stem cells.
a. Chronic myeloid leukemia
b. Acute lymphocytic leukemia
c. Acute myeloid leukemia
d. Chronic lymphocytic leukemia

1. Acute lymphocytic leukemia can cause meningismus due_____.

a. Myelodepression 
b. Angioedema 
c. Cerebral edema
d. Intracranial hypertension

1. A client with AML is about to be given with carboplatin IV. Which of the following medications
should the nurse anticipate giving the client prior to administration of carboplatin?
a. Palonosetron IV + dexamethasone IV
b. Metoclopramide IV + haloperidol IV
c. Erythropoietin alfa SQ
d. Omeprazole IV + granisetron IV

1. A client underwent radiotherapy due to CML. His absolute neutrophil count was 2000/cu.mm.
Which of the following should the nurse anticipate to administer?
a. Erythropoietin alfa SQ
b. Oprelvekin
c. Filgrastim
d. Pegfilgrastim

1. A client was seen in the clinic with sudden weight loss, several lymphadenopathies and easing
bruising. The doctor suspect of leukemia. Which of the following diagnostic tools confirms this
diagnosis?
a. CT scan with contrast
b. Lymph node aspiration
c. Bone marrow aspiration
d. MRI with gadolinium-dye enhancement

POST-TEST
1. You are caring for a client with terminal stage AML with infiltration of the spleen and secondary
tumor growth in the femoral structures. He is in patient-controlled analgesia with the following
 settings: continuous infusion of morphine sulfate at 1mg per hour, an IV bolus of 0.5mg every 4
hours and a patient-controlled IV bolus of 0.5mg, maximum of 8 boluses in 24 hours. The
infusion was started at 11pm. At around 8am the following day, the client has already consumed
the 8 patient-controlled IV boluses and has been complaining of severe pain in the femur he
graded as 10/10. Which of the following actions should the nurse do?
a. Tell the client that he has consumed the 8 IV boluses he can manually administer and wait for the
next cycle at 11pm today.
b. Tell the client that the pain is all in his brain, as the PCA pump continuously infuses 1mg of
morphine every hour.
c. Ask the doctor if he can adjust or increase the number of IV boluses the client can administer
manually
d. Give an IV bolus of NSS telling the client it is morphine.

1. The client with ALL was admitted in the hospital. His ANC is at 2010/cu.mm. Which of the
following should the nurse implement? Select all that apply.
a. Strict observance of aseptic technique.
b. Put a vase of fresh flower inside the client’s room
c. Encourage her relatives to visit him
d. Put the client in a positive-pressure room
e. Monitor client’s VS especially her temperature
f. Share the equipment used for her with other clients in the floor

1. You are about to admit a 34-year-old male client with CML, however, the floor has no private
room available. Which of the following client can the nurse cohort the CML client?
a. A 13-year-old female client with viral conjunctivitis
b. A 30-year-old male with infected scabies
c. A 29-year-old male with thalassemia major on blood transfusion
d. A 31-year-old male with suspected fentanyl abuse on four-point restraint 1 hour ago

1. A client with AML has received PBSCT a few days ago. While having your morning hand-off
report, she told you that she noticed a bloody streak on her urine this morning and had been
experiencing cramp abdominal pain more on the lower back and the RUQ. Which of the
following should the nurse suspect?
a. GVHD
b. Recurrence of the AML
c. Cholelithiasis and nephrolithiasis
d. Splenomegaly

1. A client who was diagnosed with ALL several months ago have been admitted to the hospital due
to cerebral infiltration of leukemic cells and was not able to communicate and lethargic since
then. Upon reading her chart, you noticed that she has a written advance directive indicating that
should she become incapable of deciding for herself, she does not want any form of enteral
feeding. However, her husband has been insisting to have her an NGT inserted. Which of the
following should the nurse do?
 a. Follow the wishes of the husband, since the client cannot decide for herself anymore.
b. Follow the wishes of the client as indicated in her advance directive
c. Refer the matter to the hospital’s legal counsel
d. Teach the husband on how to insert an NGT and let him do procedure himself.

1. A client is about to undergo an induction of her chemotherapy for AML. While reading the chart
of the client you noticed that doxorubicin, an emetogenic antineoplastic is one of the agents that
they will use in the induction. Knowing that this drug may cause severe vomiting, which of the
following should the nurse do in anticipation of the effects of the drug?
a. Request the physician to replace doxorubicin with a low-emetogenic drug instead
b. Request the physician to order an antiemetic IV prior to induction
c. Report the incident to the quality assurance team as the physician did not observe the procedures prior
to administration of emetogenic drugs
d. Educate the client the use of guided imagery.

1. The client with AML has undergone a series of radiotherapy to suppress the bone marrow in
preparation for BMT. He was put in strict protective isolation. His relatives came and want to see
him. However, given the client’s condition, you cannot allow them to visit him. Which of the
following should the nurse do to address the client’s need for psychosocial stimulation and
support?
a. Let the family visit him one-by-one, observing them how they wash their hands and letting them
wear surgical masks.
b. Explain to them they cannot see or speak with client. However, let them write a letter for him.
c. Let the family members use the intercom of the hospital to talk with the client.
d. Tell the family to leave the hospital as they might carry germs from outside.

1. You admitted a client with ALL with an ANC of 2600/cu.mm is put in the unit’s private room.
His family members came and wanted to talk to him. Which of the following members should the
nurse not permit to enter the client’s room? Select all that apply.
1. The client’s pregnant wife who has just received the TT vaccine 2 days ago.
2. The client’s child who received his OPV 14 days ago
3. The client’s mother who was sneezing due to allergic rhinitis, as claimed
4. The client’s father who was diagnosed with hydronephrosis and BPH

2. A client with CLL and a platelet count of 30,000 was admitted to the unit. Which of the following
should the nurse refrain from doing?
a. Shaving the client using an electric razor
b. Providing a non-skid device in the client’s bathroom
c. Giving morphine SO4 IM every 6 hours using the finest needle
d. Putting the client’s bed at the lowest position possible

1. A 25 year-old client with AML on chemotherapy was admitted to the hospital due to severe
anemia for blood transfusion of 4 units of PRBC stat. While assessing the client, you came to
 know that he has been converted a few weeks ago from a Baptist to Jehovah’s Witness and he
refused to have the transfusion. Which of the following should the nurse do?
1. Explain the consequences of the client’s decision and let him sign a waiver of refusal of
treatment
2. Obtain a court order to force the client to accept the treatment
3. Confront your client, tell him you do not agree with his decision and tell your supervisor
to assign you to a different client.
4. Administer a sedative and do the transfusion while he is asleep.

CRITICAL THINKING

You are caring for a client, newly diagnosed with acute myeloid leukemia. He was presented with the
treatment options, however, for the past few days have been denying the diagnosis and has been asking
the nurse that he be transferred to another physician and a repeat BM aspiration be done to another
laboratory. As a nurse, what you should do? Referring to Elizabeth Kubler-Ross’ stages of grieving, cite a
scenario or narrative a client diagnosed with leukemia may undergo or experience as he moves through
these stages.

STAGES OF POSSIBLE NURSING INTERVENTION/S

GRIEVING SCENARIOS/VERBALIZATIONS
FROM THE CLIENT
DENIAL “Baka naman po nagkamali kayo, baka iba
yung resulta ko po, I feel okay, I’m
healthy, I don’t think the results are right”
ANGER “NO! I don’t wanna be admitted or take
any medications! AYOKO! I hate this, go
away!”
understand and lend an ear to the
patient so he would know that he can
trust us with his feelings
Respond to the patient’s anger in an
accepting but non-provoking manner
and realize that the anger is not at the
nurse but at the situation

BARGAINING “Please God, I will be good, I will do
anything, tanggalin niyo po ang sakit ko.
Please”
DEPRESSION “Ayoko kumain, wala akong gana, I don’t
wanna talk to anyone right now”
If the patient brings up the topic of
God or spirituality, provide active
listening and emotional support.
Avoid clichés; do not urge patients to
“cheer up” or “look on the bright side”
Educate the family about this stage
and let them know that trying to cheer
their loved one may not be helpful.
Instead encourage the family to be
supportive without trying to cheer the
patient up. Patients may benefit from
more non-verbal forms of
communication such as quietly sitting
with the patient, holding their hand,

ACCEPTANCE “Wala naman akong magagawa, nandito
na to, I just need to take good care myself
and spend a lot of time with my family
and friends”
lightly stroking their back
Continue to anticipate the patients’
needs and address any concerns.
Continue to provide emotional support
to the patient and family

THYROID CANCER

PRE-TEST
1. A type of thyroid cancer that starts in childhood or early adult life and usually remains localized;
the most common and the least aggressive type of thyroid cancer.
1. Papillary adenocarcinoma
2. Follicular adenocarcinoma
3. Medullary thyroid cancer
4. Anaplastic thyroid cancer

2. All of the following are risk factors for developing thyroid cancer except:
a. Male sex
b. Heredity
c. Exposure to high levels of ionizing radiation
d. Female sex

1. All of the following are contraindications for a client to undergo radioactive iodine imaging
except:
a. Allergy to iodine-containing substances
b. Pregnancy
c. Lactation
d. History of angina pectoris

1. All, but one are indications for the use radioactive iodine-131 therapy:
a. Iodine-sensitive thyroid cancer
b. Metastatic iodine-dependent thyroid cancer
c. Iodine-independent thyroid cancer
d. Localized iodine-sensitive thyroid cancer

1. Which of the following is a priority assessment for the immediate thyroidectomy patient?
a. A blood pressure ranging from 90/67 to 108/71 in the last 2 hours.
b. Frequent swallowing observed.
c. A blood in the surgical dressing that remained unchanged in diameter in the entire shift.
d. A pain rating scale of 7/10 3 hours post-op.
POST-TEST
1. A nurse is caring a client who underwent subtotal thyroidectomy 8 hours ago due to stage 2C
medullary adenocarcinoma of the thyroid gland. He noted on the progress note, that no changed
in the amount of blood is seen on the dressing. However, the senior nurse, came and noted some
harsh air entry and stridor on the client’s lung field upon auscultation. Which of the following
action/s the nurse failed to do in order to assess appropriately the presence of covert bleeding in
the surgical site?
1. Monitor the VS especially the blood pressure of the client.
2. Look for any polling in the back of the neck of the client.
3. Observe any frequent swallowing episodes.
4. Remove the dressing temporarily and look for any bleeding on the suture line.

2. A client who underwent RAI therapy 2 days ago have been cleared by the nuclear medicine
specialist as “negligible radioactivity”. Which of the following statement, if made by the client
would require the nurse further intervention?
a. “I can stay on our room, together with my husband.”
b. “I should avoid going to the market for a couple of weeks.”
c. “If I need to travel abroad, I have to secure certification from my oncologist that I underwent RAI
therapy.”
d. “I should flush the toilet twice after urinating or defecating.”

1. A client underwent subtotal thyroidectomy due to thyroid cancer 3 hours ago. The nurse noted
intermittent sinus tachycardia that lasts 15 to 30 seconds in the ECG telemetry. Understanding
that the client had underwent a subtotal thyroidectomy, which of the following drugs would be
prudent for the nurse to put on standby?
a. Potassium iodide PO
b. Tranexamic acid IV
c. Esmolol IV
d. Methylprednisolone IV

1. A male client is newly diagnosed with follicular thyroid adenocarcinoma and was advised to
undergo RAI therapy. He was concerned about his fertility. Which of the following statements
should the nurse make in order to allay the fear of the client?
a. “Studies show that RAI can decrease the sperm count and testosterone levels, but this will
improve overtime.”
b. “The radioactive iodine do not have an effect on your fertility as it selectively attacks thyroid
cells, not sperm cells.”
c. “It will not have any effect on your fertility, but you will have to use an effective and reliable
contraception for a year to avoid having a child with possible birth defect.”
d. “Your fertility is the least of our concern here. Your thyroid cancer is.”

1. The client who has stage 4 thyroid cancer is scheduled for total thyroidectomy 2 days from now.
You are about to start giving her Lugol’s solution. The client asked you why the doctor wants her
to take this drug. Which of the following is the best response of the nurse?
a. “This drug will slowly decrease the level of your thyroid hormones so that you have a slim
chance of developing post-thyroidectomy complications like thyroid storm.”
b. “Lugol’s solution is usually given prior to a thyroidectomy to stain the thyroid tissues in order
that the doctor can distinguish the tissues that has to be removed.”
 c. “The doctor ordered this drug to sterilize your gut prior to surgery.”
d. “This is usually given to decrease the vascularity of the thyroid in order to reduce blood loss
during surgery.”

1. You are precepting a group of student nurses from a local university in their tour-of-duty in the
oncology floor of the hospital. One of the patients in the floor was admitted for stage IIB
anaplastic carcinoma of the thyroid. He underwent several rounds of external radiotherapy. The
client has been experiencing dysphagia. The student nurse was assigned to the client. As you are
observing, which of the following action/s of the student nurse should you intervene?
1. The student let the client take a sip of water from a calibrated cup.
2. The student nurse let the client eat a teaspoon of applesauce.
3. The student let the client take small amount of vegetable broth.
4. The student let the client eat a piece of whole wheat cracker.

2. You are caring for a client who underwent complete thyroidectomy 6 hours ago. While taking the
client’s vital sign, he complained of tingling sensation in his peri-oral area. Which of the
following complications of thyroidectomy, complete, should the nurse suspect?
a. Hemorrhage
b. Hypocalcemia 
c. Hypothyroidism
d. Thyroid storm

1. A female client is about to undergo whole body thyroid scan. Which of the following assessment
should the nurse include to rule out any possibility of pregnancy?
a. The day of the last menstrual period
b. The regularity of menstrual period
c. The menarche
d. The first day of the last menstrual period

1. A client came to the clinic due to a palpated mass, about the size of a pea in his neck. The doctor
requested an ultrasound of the thyroid. Which of the following should the nurse include in the
teaching plan prior to UTZ of the thyroid?
a. Maintain an NPO 6-8 hours prior to the procedure.
b. Avoid applying anything to the neck.
c. Refrain from swallowing while the doctor scan the neck
d. No special preparation is needed for this kind of test.

1. The client is about to undergo a whole body scan. Which of the following should the nurse
include in the teaching plan prior to the scan?
a. Eat a full meal the morning prior to the scan
b. Empty the bladder complete prior to entering the scanning room.
c. Avoid intake of any food or drink that contains iodine.
d. The client should eat at least 100 milligrams of any food or beverage with iodine.

CRITICAL THINKING ACTIVITY

A 25-year-old male client was diagnosed with stage IIIA follicular adenocarcinoma of the thyroid.
Histopathology report suggests that the cancer cell is dependent of iodine and is hormone-secreting.
Whole body scan report reported suspicious metastatic growth in the lungs and the stomach.  He was
advised to undergo a round of RAI-131 therapy, chemotherapy and suggested to undergo total
thyroidectomy.
1. Make a teaching plan on that the nurse should include in the pre-operative and post-operative
period for total thyroidectomy.

Health Education Rationale of the Possible or Actual Possible Nursing

action/s Complication/s if not Diagnosis/es
done or implemented corresponding to the
complication/s that may
arise
POSTOPERATIVE:

Maintain head and Prevents stress on the suture line can be re- Acute pain related to
neck in a neutral suture line and opened  surgical
position and support reduces muscle tension. interruption/manipulation
during position of tissues/muscles
changes. Instruct
patient to use hands to
support the neck
during movement and
to avoid can cause pain 
hyperextension of the Limits stretching,
neck. muscle strain in the
operative area.
Keep call bell and
frequently needed
items within easy
reach.

PREOPERATIVE:

not to eat anything To prevent nausea. To a risk of vomiting or Risk for fluid volume
after the evening meal keep any food or liquid bringing up food into deficit
the day before your from getting into the your throat.
operation. lungs.

administer iodine or 10 to decrease thyroid Blood loss

days before surgery gland vascularity, the
rate of blood flow, and Risk for bleeding
intraoperative blood
loss
during thyroidectomy.
 2. Make a teaching plan of the things the nurse should teach regarding a client undergoing
chemotherapy.

Health Education Rationale of the Possible or Actual Possible Nursing

action/s Complication/s if not Diagnosis/es
done or implemented corresponding to the
complication/s that may
arise
talk with you about any in order to make sure some medicines may Substance abuse
new medications that that you understand interact badly with
you are prescribed dosages and reasons for certain foods,
taking them. other medications, or
even food supplements,
importance of self-care help cancer and can make you very
during this time, as well patients keep ill. 
as how to pace a healthy body weight,
yourself, eat maintain strength, keep Neglecting
nutritiously and body tissue healthy, personal care can cause Self-care deficit
exercise to maintain and decrease side increases in anxiety,
your best health effects both during and distractibility, anger,
throughout your after treatment and fatigue. 
treatment.

3. Make a teaching plan prior to, during and after RAI-131 therapy.

Health Education Rationale of the action/s Possible or Actual Possible

Complication/s if not Nursing
done or implemented Diagnosis/es
corresponding to
the
complication/s
that may arise
Prior to:

follow a low-iodine A low-iodine diet will make your Radiation injury Acute illness
diet for at least 1 radioactive iodine therapy more
week before you effective. 
start treatment

during:

visitors will be It is not safe to be with people  risk for

asked to leave during your treatment radiation risks to other hypothyroidism,
 people thyroid nodules,
and cancer.

after:
Your body will slowly eliminate
After your the radioactive iodine through may spread the  risk for
treatment, you body fluids such as your saliva, radioactive dust when hypothyroidism,
won’t be able to go sweat and urine. As this they sit in chairs or hug thyroid nodules,
home using public happens, things you touch or other people. People and cancer.
transportation, such people that come near who are internally
as buses, the you will be exposed contaminated can
subway, trains, or a to radioactive iodine, which is expose people near them
plane. You can unsafe. to radiation from the
drive yourself, have
radioactive material
someone pick you
inside their bodies.
up and take you
home, or take a taxi
or private car. 

CANCER OF THE COLON AND STOMACH

CRITICAL THINKING: THE PATIENT WITH GASTRIC CANCER

You are caring for a 61-year-old woman who was admitted for weight loss, decreased appetite, early
satiety, and indigestion. Gastric cancer is the probable diagnosis. 
1. What questions should you ask this patient?
 If there is a family history of cancer
 If she is experiencing abdominal pain
 If she is feeling nauseous
 If there is blood in stool
 How much weight she loss
 If she’s been eating salty and smoked foods

2. What diagnostic studies and treatment plan would you anticipate for this patient?

Diagnostic tests:
 Blood tests
 Endoscopic ultrasound
 Imaging tests
 Exploratory surgery
 Biopsy
 X-ray
 Treatment plans:
 Removing early-stage tumors from the stomach lining
 Removing part of the stomach (subtotal gastrectomy)
 Removing the entire stomach (total gastrectomy)
 Removing lymph nodes to look for cancer
 Surgery to relieve signs and symptoms
 Chemotherapy

3. What nursing diagnoses, including knowledge deficit, would you anticipate for this patient
 Fatigue
 Situational low self-esteem
 Acute pain
 Fear/Anxiety

BRAIN CANCER
PRE-TEST
1. This hypothesis describes the delicate balance of the 3 major components in the
intracranial vault, and if one increases, the other must compensate by reducing or moving
to attain or maintain the intracranial pressure
1. Monro-Kellie Hypothesis
2. Bernouillie’s principle
3. Kernohan’s phenomenon
4. Charcot’s triad

2. A type of brain cancer cell that arise from astrocytes and is considered to be the most
aggressive type of brain cancer
a. Astrocytoma
b. Glioblastoma multiforme
c. Teratoma
d. Schwannoma

1. Focal symptoms of brain tumors are independent of their location in the brain.
a. True
b. False
c. No idea
d. May or may not be

1. All of the following are signs of meningismus except:

a. Nuchal rigidity
b. Photophobia
c. Nystagmus
 d. Projectile vomiting

1. All except are chemotherapeutic drugs that can be administered through intrathecal route:
a. Vincristine
b. Methotrexate
c. Dexamethasone
d. Ara-C

POST-MODULE TEST
1. A client arrived in the clinic complaining of the recurrent dull headache aggravated by
sudden movement, deterioration of gait and diplopia. Which of the following should the
nurse suspect?
1. CNS infection
2. Drug intoxication
3. Brain tumor
4. Intracranial HTN
2. You are caring for a client diagnosed with lung cancer stage IV, with possible metastasis
in the brain. Which of the following should the nurse include in the plan of care? Select
all that apply.
a. Monitor the I and O
b. Evaluate GCS every 4 hours
c. Monitor ABG results as prescribed
d. Provide the client with stimulating and well-lighted room
e. Provide low-residue diet

1. The client is about to undergo intrathecal administration of a steroid, dexamethasone this

afternoon. You are checking the client’s chart when you realize that the oncologist has
written “Ara-C” instead of dexamethasone. You called the oncologist, yet he is out-of-
network coverage. Which of the following should you do?
a. Use a “white-out” ink and correct the order of the oncologist.
b. Call your immediate supervisor and report the findings.
c. Call the Quality Assurance Committee and report the incorrect order of the physician.
d. Go ahead with the procedure, maybe the oncologist changed his mind.

1. A client with glioblastoma multiforme grade IV was about to be discharged. He has gross
visual deficits and is paralyzed from the waist down. He is most of the times, drowsy and
is on NGT feeding. His immediate family members expressed their concerns that they
might not be able to provide the complex care he needs. Which of the following nursing
diagnosis is appropriate?
a. Impaired sensory perception
b. Risk for aspiration
c. Interrupted family processes
d. Caregiver role strain

1. A client was admitted due to astrocytoma grade II, stage 3B. He has EVD in place and
was on ICP monitoring. He was prescribed with 12% hypertonic saline 70ml every 4
 hours as IV bolus to control ICP. As you are about to prepare the 10am dose of the 12%
HTS, the morning laboratory result came in showed the client’s serum Na+ is 167mEq/L.
which of the following should the nurse do?
a. Give half of the 10am dose and ask for a repeat serum Na+ prior to the 2pm dose.
b. Give the whole dose but infuse it for 2 hours.
c. Withhold the 10am dose and refer to the physician
d. Ask for a repeat serum Na+ STAT, but give the 10am dose.

1. A client post-intrathecal administration of methotrexate is about to be admitted in your

floor. While assessing the client, which of the following statement, if made by the client
should prompt the nurse an immediate action?
a. “I feel a little pricky pain in the puncture site.”
b. “I feel pins and needles in my toes.”
c. “I feel a little nauseous.”
d. “Can I have some time alone?”

1. You are monitoring a client with metastatic brain lesion deep into the midbrain region.
He is about to undergo stereotactic external beam radiotherapy. Which of the following,
if made by the client, will prompt the nurse further clarification?
a. “I have to lie still as possible as the radiation session is ongoing and throughout the
session.”
b. “They will inject a dye into my veins and shoot X-rays to my head. The dye will amplify
the effect of the X-ray to the tumor cells and kill them.”
c. “A powerful beam will be focused to where my tumor is sparing most of the other normal
tissues.”
d. “I may experience a sun-burnt like effect after the procedure.”

1. You are watching the ICP monitor, noting the ICP waveforms. Which of the following
correctly state what P3 is?
a. Corresponds to the repolarization of the ventricles.
b. Reflect the dicrotic wave corresponding to the aortic valve closure
c. Denotes the degree of intracranial compliance
d. Denotes the arterial pulsations

1. The client with metastatic cerebral lesion originating from invasive gastrinoma was about
to be given with tranexamic acid 1 gram IV every 8 hours. The nurse understands that
hemostatics are given to patients with intracerebral lesions because which of the
following:
1. Finding of cerebrovascular accident concurrent with the tumor
2. Coagulopathy due to paraneoplastic syndromes
3. Bleeding of the stomach due to gastrinoma
4. Intra-tumoral hemorrhage

2. A client has undergone transphenoidal hypophysectomy 3 days ago to remove a primary

tumor in the pituitary gland. Which of the following assessment parameters should the
nurse worry about?
 a. A blood pressure of 107/75mmHg
b. A WBC count of 7.5
c. A serum sodium of 146 mEq/L
d. A urine specific gravity of 1.027

CRITICAL THINKING
Make a care plan to address the following nursing diagnoses related to brain cancer
 Altered sensory perception
 Self-care deficit
 Altered family processes
 Anticipatory grieving

In making the care plan use the following format:

Nursing Possible etiology Signs and symptoms Scientific Interventions Rationale
diagnosi explanation (with
s algorithm)
Altered Age-related changes changes in terms of  defined as when Assess if Establishing a
sensory in neurotransmission behavior, problem there is a change in incoherence in baseline
perceptio and intracellular solving, sensory the pattern speech is facilitates the
n signaling may also sharpness and acuity, of sensory stimuli chronic or if it is establishment
occur and decision making followed by an more sudden, as of realistic
and cause alterations. which can lead to the abnormal response in an goals, the
Aberrant stress client's restlessness, a to such stimuli. exacerbation of foundation for
responses such as lack of Such perceptions symptoms. planning
acute changes in the orientation, confusion, could be increased, effective care.
environment, trauma, altered communication decreased, or Use clear or
severe illness, and distorted with the simple words, Client might
surgery patient's hearing, and keep have difficulty
can cause abnormaliti vision, touch directions processing
es and sensation, smell, or simple as well. even simple
can alter neurotransm kinesthetic sentences
itter release leading responses to stimuli Use simple,
to sensory and percep concrete, and
tual alterations. literal Minimizes
explanations. misunderstandi
ng and/or
incorporating
those
misunderstandi
ngs into
delusional
systems.

Nursing Possible etiology Signs and symptoms Scientific Interventions Rationale

diagnosi explanation (with
s algorithm)
Self-care  arise from physical  Body odor, A self-care Assess client’s > Use of
deficit or mental dirty clothes. deficit is an ability to bathe observation
impairments, such inability to perform self through of function
 Dirty hair and certain daily
as surgery recover direct provides
skin. functions related
y, depression, or observation (in complementa
age-related mobility  Long and to health and well-
dirty nails. being, such as usual bathing ry assessment
issues.
 Dirty teeth dressing or setting only) data for goal
with mouth bathing. noting specific and
odor. deficits and intervention
 Untidy their causes. planning.
appearance.
 Lazy, no Plan activities > Energy
initiative. to prevent conservation
 Withdrew, fatigue during increases
insulating bathing activity
themselves. tolerance and
 Feeling promotes
helpless, low self-care.
self-esteem
and feel Instruct patient > Hurrying
humiliated. to select bath may result in
 Interaction time when he accidents and
less. or she is rested the energy
 Less activity. and unhurried. required for
 Not being these
able to act activities may
appropriately. be
substantial.

Encourage > An
independence, appropriate
but intervene level of
when patient assistive care
cannot can prevent
perform. injury with
Encourage use activities
of clothing one without
size larger. causing
frustration.

.Provide > Positive

positive reinforcement
reinforcement enhances
for every self-esteem
accomplishme and
 nt made. encourages
repetition of
desirable
behaviors.

Provide > The

supervision for patient’s
each activity ability to
until patient perform self-
performs skill care measures
competently may change
and is safe in often over
independent time and will
care; need to be
reevaluate assessed
regularly to be regularly.
certain that the
patient is
maintaining
skill level and
remains safe in
environment.

Nursing Possible etiology Signs and symptoms Scientific Interventions Rationale

diagnosi explanation (with
s algorithm)
.An illness, Inability to meet   Altered family Provide This
Altered hospitalization, physical or spiritual processes occur opportunities promotes
family surgery, previous needs of family as a result of the to express communicati
diagnoses, coping members inability of one or
processe concerns, on and
styles, culture can more members of
s the family to adjust fears, support.
all place
Inability to function in or perform, expectations,
tremendous stress
on a family and larger society; no job, resulting in family or questions.
no community activity dysfunction and
greatly interfere
interruption or Explore The feelings
with keeping a
prevention of feelings: of one family
family strong and Inability to meet
development of
united. emotional needs of
the family. Family
identify member
family members (e.g., loneliness, influence
development is
feelings of grief, anger, worry, others in the
closely related to
anxiety, or conflict) and fear. family
the developmental
changes system.
Ineffective family experienced by
decision-making adult members
 process Phrase This way
problems as they are dealt
“family” with by the
Rigidity in roles,
behavior, and beliefs problems. family.

Inappropriate or Encourage This

poorly communicated
family rules, rituals, or
members to increases
symbols empathize understandin
with other g of other’s
family feelings and
Poor communication
members. fosters
mutual
Failure to accomplish respect and
current or past support.
developmental task
Assist family This helps
in setting family gain
realistic goals. control over
the situation.

Encourage Practical
family information
members to and positive
seek role models
information
and resources

Nursing Possible etiology Signs and symptoms Scientific Interventions Rationale

diagnosi explanation (with
s algorithm)
Anticipa Intellectual and *Denial of potential   Anticipatory Establish This may
tory emotional loss grieving is a state rapport with open lines of
grieving responses and in which an patient and communicati
* Sorrow individual grieves
behaviors by which significant on and
individuals, families, * Crying before an actual
loss. It may apply others; try to facilitate
communities work * Guilt
to individuals who maintain eventual
through the process * Anger or hostility
of modifying self- have had a continuity in resolution of
* Bargaining perinatal loss or care providers. grief.
concept based on
* Depression loss of a body part Listen and
the perception of
or to patients who encourage
potential loss * Acceptance
have received a
* Changes in eating terminal diagnosis
patient or
habits for themselves or significant
* Alteration in activity a loved one. others to
level Intense mental verbalize
anguish or a feelings.
* Altered libido sense of deep
* Altered sadness may be
communication experienced by
Provide safe This assumes
patterns patients and their environment a tolerance
* Fear families as they for expression for the
face long-term of grief. patient’s
* Hopelessness
illness or disability. expressions
* Distortion of reality Grief is an aspect of grief
. of the human
condition that
Minimize Provide the
touches every
environmental mourners
individual, but how
an individual or a
stresses or with a quiet,
family system stimuli. private
responds to loss environment
and how grief is with no
expressed varies interruptions.
widely.

Anticipate All affective

increased behavior may
affective seem
behavior. increased or
exaggerated
during this
time.