All-in-One Nursing Care Planning
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care
Clinical Scenario:
A 58-year-old patient with metastatic lung cancer is starting
treatment and reports fatigue, poor appetite, and a recent 6-kg
weight loss over 2 months. Vital signs are stable, and there are
no signs of infection or acute pain.
Question Stem:
Which nursing diagnosis should the nurse prioritize for the
initial care plan?
Answer Options:
A. Risk for infection related to immunosuppression
B. Imbalanced nutrition: less than body requirements related to
decreased oral intake
C. Acute pain related to tumor progression
D. Ineffective breathing pattern related to pleural effusion
Correct Answer:
B. Imbalanced nutrition: less than body requirements related
to decreased oral intake
Detailed Rationale:
The most immediate care-planning concern in this scenario is
the patient’s significant weight loss and poor appetite, which
indicate a nutrition problem that can worsen weakness, healing,
and treatment tolerance. While cancer patients are at risk for
infection, there are no cues of infection here. Pain and
,respiratory issues are not the priority because the scenario
does not present acute evidence of either.
Incorrect Option Analysis:
• A: Incorrect because the patient has risk factors, but no
current cues of infection. A common misconception is to
prioritize every risk diagnosis over actual nutritional
decline.
• C: Incorrect because pain is not described as current or
severe.
• D: Incorrect because no respiratory distress, abnormal lung
findings, or dyspnea are present.
Nursing Process Linkage: Diagnosis
NCJMM Competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Imbalanced nutrition: less than
body requirements
• Related Factors: Decreased appetite, altered taste,
increased metabolic demand
, • Defining Characteristics: Weight loss, fatigue, poor intake
Expected Outcome:
Patient will maintain or improve nutritional intake and
stabilize weight within the treatment period.
Key Learning Objective:
Identify a priority nursing diagnosis in cancer care planning
based on assessment cues.
2) SATA — Chemotherapy / Neutropenia
Clinical Scenario:
A patient is 10 days after a chemotherapy cycle and reports a
sore throat and chills. Temperature is 38.3°C (100.9°F), ANC is
700/mm³, and the oral mucosa is inflamed.
Question Stem:
Which nursing actions should the nurse include in the care
plan? Select all that apply.
Answer Options:
A. Initiate neutropenic precautions
B. Notify the provider and anticipate blood cultures
C. Encourage fresh flowers at the bedside for comfort
D. Avoid rectal temperatures and rectal medications
E. Teach the patient to report fever immediately after discharge
F. Encourage raw fruits and salads to improve intake
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ — Cancer Care
Clinical Scenario:
A 58-year-old patient with metastatic lung cancer is starting
treatment and reports fatigue, poor appetite, and a recent 6-kg
weight loss over 2 months. Vital signs are stable, and there are
no signs of infection or acute pain.
Question Stem:
Which nursing diagnosis should the nurse prioritize for the
initial care plan?
Answer Options:
A. Risk for infection related to immunosuppression
B. Imbalanced nutrition: less than body requirements related to
decreased oral intake
C. Acute pain related to tumor progression
D. Ineffective breathing pattern related to pleural effusion
Correct Answer:
B. Imbalanced nutrition: less than body requirements related
to decreased oral intake
Detailed Rationale:
The most immediate care-planning concern in this scenario is
the patient’s significant weight loss and poor appetite, which
indicate a nutrition problem that can worsen weakness, healing,
and treatment tolerance. While cancer patients are at risk for
infection, there are no cues of infection here. Pain and
,respiratory issues are not the priority because the scenario
does not present acute evidence of either.
Incorrect Option Analysis:
• A: Incorrect because the patient has risk factors, but no
current cues of infection. A common misconception is to
prioritize every risk diagnosis over actual nutritional
decline.
• C: Incorrect because pain is not described as current or
severe.
• D: Incorrect because no respiratory distress, abnormal lung
findings, or dyspnea are present.
Nursing Process Linkage: Diagnosis
NCJMM Competencies: Recognize Cues, Analyze Cues, Prioritize
Hypotheses
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Nursing Diagnosis Integration:
• Priority Nursing Diagnosis: Imbalanced nutrition: less than
body requirements
• Related Factors: Decreased appetite, altered taste,
increased metabolic demand
, • Defining Characteristics: Weight loss, fatigue, poor intake
Expected Outcome:
Patient will maintain or improve nutritional intake and
stabilize weight within the treatment period.
Key Learning Objective:
Identify a priority nursing diagnosis in cancer care planning
based on assessment cues.
2) SATA — Chemotherapy / Neutropenia
Clinical Scenario:
A patient is 10 days after a chemotherapy cycle and reports a
sore throat and chills. Temperature is 38.3°C (100.9°F), ANC is
700/mm³, and the oral mucosa is inflamed.
Question Stem:
Which nursing actions should the nurse include in the care
plan? Select all that apply.
Answer Options:
A. Initiate neutropenic precautions
B. Notify the provider and anticipate blood cultures
C. Encourage fresh flowers at the bedside for comfort
D. Avoid rectal temperatures and rectal medications
E. Teach the patient to report fever immediately after discharge
F. Encourage raw fruits and salads to improve intake
