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
Question Number and Type: 1 — MCQ
Clinical Scenario:
A 58-year-old client is receiving external beam radiation for lung
cancer. At today’s visit, the client reports “feeling wiped out,”
has dry, mildly reddened skin over the treatment field, and says
food tastes “off,” so they are eating less.
Question Stem:
Which nursing intervention is the priority to include in the
client’s care plan?
Answer Options:
A. Apply a heating pad to the reddened skin twice daily
B. Teach the client to protect the treatment area from friction,
avoid harsh products, and plan rest periods
C. Encourage vigorous exercise to improve appetite and energy
D. Restrict fluids to prevent nausea during treatment
Correct Answer:
B
Detailed Rationale:
Radiation commonly causes fatigue and localized skin changes
in the treatment area, so the care plan should focus on
protecting skin integrity and conserving energy. Teaching the
,client to avoid friction/irritants and to plan rest periods
supports symptom management and safety. Cancer treatment
side effects often affect energy intake and daily functioning, and
skin reactions are expected toxicities that need preventive
teaching.
Incorrect Option Analysis:
A. Incorrect. Heat can worsen radiation-related skin irritation
and increase injury risk. The misconception is that heat always
soothes inflamed tissue.
C. Incorrect. Overexertion can worsen cancer-related fatigue;
activity should be paced, not vigorous. The misconception is
that more exercise is always better regardless of symptom
burden.
D. Incorrect. Fluid restriction can worsen dehydration and
overall tolerance of treatment. The misconception is that less
intake always reduces nausea.
Nursing Process Linkage:
Planning
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Generate Solutions; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
, NCLEX Client Needs Category:
Physiological Adaptation
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Fatigue related to cancer treatment
and altered nutritional intake
Related Factors: Radiation effects, reduced oral intake
Defining Characteristics: Verbalized exhaustion, decreased
appetite, reduced activity tolerance
Expected Outcome:
The client will verbalize two skin-protection measures and will
report using planned rest periods within 24 hours.
Key Learning Objective:
Develop a nursing care plan that addresses common radiation-
related fatigue and skin impairment.
2) SATA
Question Number and Type: 2 — SATA
Clinical Scenario:
An 82-year-old postoperative client is intermittently confused,
pulls at IV tubing, drinks very little, and has slept poorly for 2
nights. The family reports the client is “not acting like
themselves.”
Resource
Medical-Surgical, Pediatric,
Maternity, and Psychiatric-Mental
Health
5th Edition
• Author(s)Pamela L. Swearingen;
Jacqueline Wright
TEST BANK
,1) MCQ
Question Number and Type: 1 — MCQ
Clinical Scenario:
A 58-year-old client is receiving external beam radiation for lung
cancer. At today’s visit, the client reports “feeling wiped out,”
has dry, mildly reddened skin over the treatment field, and says
food tastes “off,” so they are eating less.
Question Stem:
Which nursing intervention is the priority to include in the
client’s care plan?
Answer Options:
A. Apply a heating pad to the reddened skin twice daily
B. Teach the client to protect the treatment area from friction,
avoid harsh products, and plan rest periods
C. Encourage vigorous exercise to improve appetite and energy
D. Restrict fluids to prevent nausea during treatment
Correct Answer:
B
Detailed Rationale:
Radiation commonly causes fatigue and localized skin changes
in the treatment area, so the care plan should focus on
protecting skin integrity and conserving energy. Teaching the
,client to avoid friction/irritants and to plan rest periods
supports symptom management and safety. Cancer treatment
side effects often affect energy intake and daily functioning, and
skin reactions are expected toxicities that need preventive
teaching.
Incorrect Option Analysis:
A. Incorrect. Heat can worsen radiation-related skin irritation
and increase injury risk. The misconception is that heat always
soothes inflamed tissue.
C. Incorrect. Overexertion can worsen cancer-related fatigue;
activity should be paced, not vigorous. The misconception is
that more exercise is always better regardless of symptom
burden.
D. Incorrect. Fluid restriction can worsen dehydration and
overall tolerance of treatment. The misconception is that less
intake always reduces nausea.
Nursing Process Linkage:
Planning
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Generate Solutions; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
, NCLEX Client Needs Category:
Physiological Adaptation
Nursing Diagnosis Integration:
Priority Nursing Diagnosis: Fatigue related to cancer treatment
and altered nutritional intake
Related Factors: Radiation effects, reduced oral intake
Defining Characteristics: Verbalized exhaustion, decreased
appetite, reduced activity tolerance
Expected Outcome:
The client will verbalize two skin-protection measures and will
report using planned rest periods within 24 hours.
Key Learning Objective:
Develop a nursing care plan that addresses common radiation-
related fatigue and skin impairment.
2) SATA
Question Number and Type: 2 — SATA
Clinical Scenario:
An 82-year-old postoperative client is intermittently confused,
pulls at IV tubing, drinks very little, and has slept poorly for 2
nights. The family reports the client is “not acting like
themselves.”
