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A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?
- A. Assess the client for calf pain, warmth, and redness.
- B. Instruct the client to call for help to get out of bed.
- C. Obtain cultures as per the facility's standing policy.
- D. Place the client on protective Isolation Precautions.
Correct Answer: B
Rationale: A platelet count of 9800/mm³ indicates severe thrombocytopenia, placing the client at high risk for bleeding, even with minor trauma or injury. Instructing the client to call for help before getting out of bed ensures they receive assistance with mobility, which reduces the risk of falls or injuries that could lead to serious bleeding. Preventing any activity that could result in trauma is crucial when managing clients with very low platelet counts.
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A client is admitted to the hospital with a suspected diagnosis of Hodgkin¢â‚¬â„¢s disease. Which assessment finding would the nurse expect to note specifically in the client?
- A. Fatigue
- B. Weakness
- C. Weight gain
- D. Enlarged lymph nodes
Correct Answer: D
Rationale: Hodgkin's disease (Hodgkin's lymphoma) is a type of cancer that originates in the lymphatic system, particularly affecting the lymph nodes. A hallmark sign of Hodgkin's disease is the painless enlargement of lymph nodes, often in the neck, armpit, or groin. These enlarged lymph nodes are typically firm and rubbery to the touch. This is one of the most distinctive and common early signs that healthcare providers look for when diagnosing the disease.
The nurse is instructing the 35 year old client to perform a testicular self-examination. The nurse tells the client:
- A. To examine the testicles while lying down
- B. That the best time for the examination is after a shower
- C. To gently feel the testicle with one finger to feel for a growth
- D. That testicular self-examination should be done at least every 6 months
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client who is at risk for tumor lysis syndrome. Which laboratory value requires the nurse to intervene?
- A. Decreased blood urea nitrogen (BUN)
- B. Increased serum calcium
- C. Increased creatinine level
- D. Increased blood glucose level
Correct Answer: C
Rationale: Tumor lysis syndrome (TLS) is a potentially life-threatening condition that occurs when large numbers of cancer cells die rapidly, releasing their contents into the bloodstream. This can overwhelm the kidneys and lead to acute kidney injury. Creatinine is a waste product filtered out of the blood by the kidneys, and an elevated creatinine level is a sign of kidney dysfunction or damage. In TLS, increased creatinine levels indicate that the kidneys are struggling to filter out the excess waste products from cell breakdown, requiring immediate intervention to prevent further complications, such as acute renal failure.
An oncology nurse educator is providing health education to a patient who has been diagnosed with skin cancer. The patient¢â‚¬â„¢s wife has asked about the differences between normal cells and cancer cells. What characteristic of a cancer cell should the educator cite?
- A. Malignant cells contain more fibronectin than normal body cells.
- B. Malignant cells contain proteins called tumor-specific antigens.
- C. Chromosomes contained in cancer cells are more durable and stable than those of normal cells.
- D. The nuclei of cancer cells are unusually large, but regularly shaped.
Correct Answer: B
Rationale: Malignant (cancer) cells often express tumor-specific antigens (TSAs), which are proteins or markers on the surface of cancer cells that are not found on normal cells. These antigens are produced due to genetic mutations in cancer cells and can sometimes be used to help the immune system recognize and attack cancerous cells. Tumor-specific antigens play a key role in cancer diagnosis, monitoring, and targeted therapies.
Nurse Mandy is teaching a client about the side effects of radiation therapy. Which of the following should the nurse emphasize?
- A. Radiation therapy is painless.
- B. You may experience hair loss.
- C. Fatigue is a common side effect.
- D. You may experience nausea and vomiting.
Correct Answer: C
Rationale: Fatigue is one of the most frequent and profound side effects of radiation therapy. It often occurs because radiation can damage both cancerous and healthy cells, and the body requires energy to repair the damage caused by the treatment. Fatigue from radiation can be cumulative, meaning it may worsen as treatments progress, and can significantly affect the client's daily activities, requiring the nurse to educate the client on energy conservation techniques.