Nokea
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 client has been prescribed epoetin alfa for anemia related to chemotherapy. What lab value should the nurse monitor to determine the effectiveness of this medication?
- A. Hemoglobin level.
- B. Hematocrit level.
- C. White blood cell count.
- D. Platelet count.
Correct Answer: A
Rationale: Epoetin alfa is a medication used to treat anemia, particularly anemia related to chemotherapy or chronic kidney disease. It stimulates the bone marrow to produce more red blood cells, which increases the hemoglobin level. Monitoring hemoglobin is the best way to assess the effectiveness of epoetin alfa, as an increase in hemoglobin indicates that the body is producing more red blood cells and the anemia is improving.
A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the patients care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic effect of multiple myeloma most contributes to this risk?
- A. Labyrinthitis
- B. Left ventricular hypertrophy
- C. Decreased bone density
- D. Hypercoagulation
Correct Answer: C
Rationale: In multiple myeloma, the malignant proliferation of plasma cells within the bone marrow leads to the secretion of osteoclast-activating factors, which increase the breakdown of bone tissue (osteolysis). This results in decreased bone density, osteoporosis, and osteolytic lesions, making bones fragile and more prone to pathologic fractures. Patients with multiple myeloma are at high risk for fractures even with minimal trauma due to the weakened bone structure, which is why Risk for Injury is a key diagnosis.
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.
A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?
- A. Risk for Ineffective Tissue Perfusion
- B. Risk for Imbalanced Fluid Volume
- C. Risk for Ineffective Breathing Pattern
- D. Risk for Ineffective Thermoregulation
Correct Answer: A
Rationale: Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by an abnormally high platelet count, which increases the risk of hypercoagulation and thrombosis (blood clot formation). These clots can impair blood flow to tissues, leading to ineffective tissue perfusion. Thrombotic events, such as strokes, deep vein thrombosis, or myocardial infarctions, are common complications of ET, making Risk for Ineffective Tissue Perfusion the most critical nursing diagnosis to prioritize. The goal of nursing interventions will be to prevent clot formation and ensure adequate blood flow to tissues.
A patient diagnosed with polycythemia vera presents to the clinic for routine bloodwork. What should the nurse monitor for in this patient as a priority?
- A. Hemoglobin and hematocrit levels
- B. Platelet count
- C. White blood cell count
- D. Blood pressure
Correct Answer: B
Rationale: In polycythemia vera, there is an overproduction of red blood cells, white blood cells, and platelets, which leads to increased blood viscosity and a high risk for thrombosis (blood clot formation). Monitoring the platelet count is a priority because elevated platelet levels contribute significantly to the risk of developing blood clots, which can result in life-threatening complications such as strokes, heart attacks, or deep vein thrombosis (DVT). Therefore, regular monitoring of the platelet count is essential to assess the patient's risk for thrombosis and to guide treatment decisions, such as phlebotomy or medication adjustments to lower platelet levels.