Nokea
While a patient is receiving beta-1b interferon every other day for multiple sclerosis, which serum laboratory test findings should the nurse monitor to assess for possible bone marrow suppression caused by the medication? (Select all that apply)
- A. Platelet count
- B. White blood cell count (WBC)
- C. Sodium and potassium
- D. Red blood cell count (RBC)
Correct Answer: A
Rationale: Beta-1b interferon can lead to bone marrow suppression, impacting blood cell production. Therefore, monitoring the platelet count, white blood cell count (WBC), and red blood cell count (RBC) is essential. Platelet count is a direct indicator of bone marrow function and can show early signs of bone marrow suppression. While sodium, potassium, and albumin/protein levels are important for overall health assessment, they are not directly associated with bone marrow suppression caused by the medication.
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A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor for signs of activity intolerance
- B. Require visitors to wear respiratory masks
- C. Assess urine and stool for occult blood
- D. Obtain client's temperature q4 hours
Correct Answer: C
Rationale: The correct answer is to assess urine and stool for occult blood. With a low platelet count, there is an increased risk of bleeding. Monitoring for occult blood is essential to detect any signs of internal bleeding. Choices A, B, and D are not the priority interventions in this situation. While monitoring for signs of activity intolerance, requiring visitors to wear respiratory masks, and obtaining the client's temperature are important aspects of care, they are not as critical as assessing for occult blood in a client with a low platelet count.
Several months after a foot injury, an adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will 'finally go away.' How should the nurse respond?
- A. Explain that healing from the injury can take many months.
- B. Assist the client in developing a goal of managing the pain.
- C. Encourage the client to verbalize her fears about the pain.
- D. Complete an assessment of the client's functional ability.
Correct Answer: B
Rationale: The correct answer is B: 'Assist the client in developing a goal of managing the pain.' In cases of chronic neuropathic pain, complete resolution is often not achievable. Therefore, the most appropriate approach is to help the client develop strategies to manage the pain effectively. Choice A is incorrect because it may give false hope of immediate resolution, which is unlikely with neuropathic pain. Choice C is incorrect as it does not directly address the client's need for pain management. Choice D is incorrect as it focuses on functional ability assessment, which is not the priority when addressing the client's pain concerns.
Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?
- A. Intravenous administration of thyroid hormones
- B. Oral administration of hypnotic agents
- C. Intravenous bolus of hydrocortisone
- D. Subcutaneous administration of vitamin K
Correct Answer: A
Rationale: The correct answer is A: Intravenous administration of thyroid hormones. Myxedema coma is a severe form of hypothyroidism that necessitates immediate replacement of thyroid hormones. Administering thyroid hormones intravenously ensures rapid absorption and effectiveness in managing the condition. Choice B, oral administration of hypnotic agents, is incorrect as it does not address the primary issue of thyroid hormone deficiency in myxedema coma. Choice C, intravenous bolus of hydrocortisone, is not the appropriate treatment for myxedema coma as adrenal insufficiency is not the primary concern in this condition. Choice D, subcutaneous administration of vitamin K, is unrelated to the management of myxedema coma and does not address the underlying thyroid hormone deficiency that characterizes this condition.
When educating a group of school-age children on reducing the risk of Lyme disease, which instruction should the camp nurse include?
- A. Wash hands frequently
- B. Avoid drinking lake water
- C. Wear long sleeves and pants
- D. Do not share personal products
Correct Answer: C
Rationale: The correct instruction to reduce the risk of Lyme disease is to wear long sleeves and pants. This helps prevent tick bites, which are the primary mode of transmission for Lyme disease. Wearing protective clothing reduces the skin's exposure to ticks, decreasing the chances of getting bitten. Washing hands frequently (Choice A) is important for general hygiene but not specifically for preventing Lyme disease. Avoiding drinking lake water (Choice B) is unrelated to the prevention of Lyme disease. Not sharing personal products (Choice D) is important for preventing the spread of infections but does not directly reduce the risk of Lyme disease.
A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse?
- A. Rectal temperature of 101°F
- B. Complaints of left shoulder pain
- C. Blood pressure of 88/50 mmHg
- D. Sustained sinus tachycardia
Correct Answer: C
Rationale: A blood pressure of 88/50 mmHg indicates possible hypovolemia or shock, which requires immediate attention. Hypotension can be a sign of decreased perfusion to vital organs, potentially leading to organ failure. The other options, such as a rectal temperature of 101°F, complaints of left shoulder pain, or sustained sinus tachycardia, while important, do not present the same level of immediate threat to the client's well-being as a critically low blood pressure.