Nokea
A child is being evaluated for possible leukemia. Which assessment finding is most likely to be present?
- A. Numerous bruises on the child's body
- B. Ruddy complexion
- C. Diarrhea and vomiting
- D. Chest pain
Correct Answer: A
Rationale: Numerous bruises are common in leukemia due to decreased platelets from bone marrow failure.
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Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply.
- A. Instruct the client to use a razor blade to shave.
- B. Avoid administering enemas to the client.
- C. Encourage participation in noncontact sports.
- D. Teach the client how to apply direct pressure if bleeding occurs.
- E. Explain the importance of not flossing the gums.
Correct Answer: B,C,D
Rationale: Avoiding enemas (B), noncontact sports (C), and teaching pressure (D) prevent bleeding in hemophilia. Razor blades (A) and avoiding flossing (E) increase bleeding risk.
The nurse writes the problem of 'grieving' for a client diagnosed with non-Hodgkin's lymphoma. Which collaborative intervention should be included in the plan of care?
- A. Encourage the client to talk about feelings of loss.
- B. Arrange for the family to plan a memorable outing.
- C. Refer the client to the American Cancer Society’s Dialogue group.
- D. Have the chaplain visit with the client.
Correct Answer: C
Rationale: Grieving requires collaborative support; ACS Dialogue group (C) provides peer support. Talking (A) is independent, outings (B) are nonspecific, and chaplain visits (D) are spiritual, not primary.
The 33-year-old client diagnosed with Stage IV Hodgkin’s lymphoma is at the five (5)-year remission mark. Which information should the nurse teach the client?
- A. Instruct the client to continue scheduled screenings for cancer.
- B. Discuss the need for follow-up appointments every five (5) years.
- C. Teach the client that the cancer risk is the same as for the general population.
- D. Have the client talk with the family about funeral arrangements.
Correct Answer: A
Rationale: Post-remission Hodgkin’s requires ongoing cancer screenings (A) due to recurrence/second cancer risk. Follow-ups are more frequent than 5 years (B), risk remains elevated (C), and funeral plans (D) are premature.
The nurse teaches a coworker about the treatment for hemophilia. The nurse instructs that the treatment will likely include periodic self-administration of which component?
- A. Platelets
- B. Whole blood
- C. Factor concentrates
- D. Fresh frozen plasma
Correct Answer: C
Rationale: A. Platelets do not contain the deficient clotting factors. B. Although whole blood contains the deficient factors, periodic administration of factor concentrates are safer. C. A person with hemophilia A is deficient in factor VIII; hemophilia B, factor IX; and von Willebrand’s hemophilia, the von Willebrand’s factor and factor VIII. Recombinant forms of the factors are available for the client to self-administer intravenously at home. D. Although fresh frozen plasma contains the deficient factors, periodic administration of factor concentrates are safer.
The client is hospitalized with a diagnosis of sickle cell crisis. Which findings should prompt the nurse to consider that the client is ready for discharge?
- A. Leukocyte count is at 7500/mm3
- B. Describes the importance of keeping warm
- C. Pain controlled at 2 on a 0 to 10 scale with analgesics
- D. Has not had chest pain or dyspnea for past 24 hours
- E. Blood transfusions effective in diminishing cell Sickling
- F. Hydroxyurea effective in suppressing leukocyte formation
Correct Answer: A, B, C, D
Rationale: leukocyte count of 7500/mm3 is within normal range (5000 to 10,000/mm3 indicates the absence of an infection). B. Keeping warm and avoiding chills will help to prevent infection. Cold causes vasoconstriction, slowing blood flow and aggravating the Sickling process. C. Acute pain is due to tissue hypoxia from the agglutination of sickled cells within blood vessels. D. The absence of symptoms of complication such as acute chest syndrome and pulmonary hypertension indicates readiness for discharge. E. RBC transfusions may help to prevent complications, but transfusions do not alter the person’s body from producing the deformed erythrocytes. F. Hydroxyurea (Hydrea) can decrease the permanent formation of sickled cells. A side effect (not therapeutic effect) of hydroxyurea is suppression of leukocyte formation.