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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.
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A patient with acute myeloid leukemia (AML) is receiving induction therapy. What is the priority nursing intervention during this phase of treatment?
- A. Administering pain management
- B. Monitoring for signs of infection
- C. Providing emotional support
- D. Monitoring fluid balance
Correct Answer: B
Rationale: Induction therapy for acute myeloid leukemia (AML) involves intensive chemotherapy aimed at achieving remission by eliminating a large number of cancerous cells. However, this aggressive treatment also severely reduces the production of healthy blood cells, including neutrophils, which leads to neutropenia (a dangerously low number of neutrophils). This makes the patient highly susceptible to infections, which can be life-threatening. Monitoring for signs of infection is critical during this phase, as infections may occur quickly and progress rapidly due to the compromised immune system. Early detection and prompt treatment of infections are vital to improving patient outcomes during induction therapy.
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.
A nurse is caring for a client admitted for Non-Hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important?
- A. Request an order for serum electrolytes and uric acid.
- B. Increase the client's IV infusion rate.
- C. Instruct assistive personnel to strain all urine.
- D. Administer an IV antiemetic.
Correct Answer: A
Rationale: The client's symptoms of nausea, flank pain, and muscle cramps are suggestive of tumor lysis syndrome (TLS), a potentially life-threatening complication of chemotherapy in which cancer cells break down rapidly, releasing large amounts of intracellular components into the bloodstream. This leads to imbalances in electrolytes (elevated potassium, phosphate, and uric acid levels, with low calcium levels), which can cause severe metabolic disturbances, including kidney damage, arrhythmias, and muscle cramps. Checking serum electrolytes and uric acid levels is crucial for diagnosing and managing TLS early, preventing further complications.
Nurse Lisa is assessing a client who has just completed radiation therapy to the neck area. Which of the following findings is most concerning?
- A. Erythema in the treated area
- B. Difficulty swallowing
- C. Dry, peeling skin
- D. Hoarseness
Correct Answer: B
Rationale: Difficulty swallowing (dysphagia) following radiation therapy to the neck area is a significant concern because it can indicate serious complications such as esophageal stricture, inflammation, or damage to the surrounding tissues, including the esophagus. This can lead to malnutrition, dehydration, or aspiration, all of which require prompt intervention. Radiation therapy can cause irritation and scarring in the esophageal and throat tissues, which may progressively worsen if not treated. Therefore, dysphagia should be addressed immediately to prevent further complications.
The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed?
- A. I should take my temperature daily and when I don't feel well.
- B. I will discard perishable liquids after sitting out for over an hour.
- C. I won't let anyone share any of my personal toiletries.
- D. It's alright for me to keep my pets and change the litter box.
Correct Answer: D
Rationale: Clients with cancer, especially those undergoing chemotherapy or other immunosuppressive treatments, are at increased risk for infections due to a weakened immune system. Changing a litter box exposes the client to pathogens such as Toxoplasma gondii and other harmful bacteria or parasites found in cat feces, which could lead to serious infections. It is recommended that immunocompromised individuals avoid activities like changing litter boxes to reduce their risk of exposure to infectious agents. A family member or caregiver should handle this task to protect the client.