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A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?
- A. Activity intolerance
- B. Impaired tissue integrity
- C. Impaired oral mucous membranes
- D. Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI
Correct Answer: D
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired clot formation and increased risk of bleeding. With a low platelet count, there is an increased risk of internal bleeding and hemorrhage, which can affect vital organs such as the brain, heart, and gastrointestinal tract. Therefore, the priority nursing diagnosis for a client with thrombocytopenia receiving chemotherapy would be Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Monitoring for signs of internal bleeding, such as changes in mental status, chest pain, and abdominal pain, is crucial to prevent potential life-threatening complications.
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During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action?
- A. Teach parents appropriate exercises.
- B. Recheck head control at next visit.
- C. Refer child for further evaluation.
- D. Refer child for further evaluation if anterior fontanel is still open. TestBankWorld.org
Correct Answer: C
Rationale: Significant head lag in an 8-month-old infant can be a concerning sign indicating potential developmental delays or muscle weakness. The most appropriate action for the nurse in this situation is to refer the child for further evaluation by a healthcare provider, such as a pediatrician or developmental specialist, to assess and address the underlying cause of the head lag. It is important to rule out any potential developmental issues early on to provide the necessary interventions and support for the infant's optimal growth and development.
Although most relapses in children with Wilms tumor occur early (within 2 yr of diagnosis) and have a favorable outcome, about 15% suffer relapse. Relapse includes all the following EXCEPT
- A. low stage (I/II) at diagnosis
- B. no prior radiotherapy
- C. anaplastic histology
- D. more than 12 mo from nephrectomy
Correct Answer: C
Rationale: Anaplastic histology is associated with a poorer prognosis and is not typically associated with favorable relapse outcomes.
A 61-year old female patient with diabetes is in the emergency department after stepping on a sharp onject while walking barefoot on the beach. The patient did not notice that the object pierced the skin unitl later that evening. What problem does she probably have?
- A. neuropathy on her peripheral
- B. nephropathy
- C. carpal tunnel syndrome
- D. macroangiopathy
Correct Answer: A
Rationale: The patient's presentation of stepping on a sharp object and not noticing the injury until later is suggestive of peripheral neuropathy, a common complication of long-standing diabetes. Peripheral neuropathy can decrease sensation in the feet, making the patient more susceptible to injuries. In diabetes, high blood sugar levels can damage the nerves throughout the body, particularly those in the extremities. This can result in decreased sensation and poor wound healing, putting the patient at risk for injuries like stepping on a sharp object without feeling it. Therefore, the likely problem the patient has is neuropathy affecting her peripheral nerves.
A 45-year old female diabetic is displaying signs of irritability and irrational behavior during an office visit. The nurse observes visible tremors in the client's hands. based on the client's history and the nurse's understanding of diabetes mellitus, the nurse interprets these findings to be signs of:
- A. hyperglycemia
- B. hyperglycemic hyperosmolar
- C. diabetic ketoacidosis (DKA) nonketosis (HHNK)
- D. hypoglycemia
Correct Answer: D
Rationale: The signs of irritability, irrational behavior, and visible tremors in the hands observed in the 45-year old female diabetic suggest hypoglycemia. Hypoglycemia occurs when blood sugar levels drop below normal levels, causing the body and brain to receive inadequate fuel. This leads to symptoms like irritability, irrational behavior, and tremors, which are signs of the brain not receiving enough glucose for proper functioning. In diabetic patients, particularly those on medications like insulin or certain oral hypoglycemic agents, hypoglycemia can occur if they take too much medication, skip meals, or engage in excessive physical activity without adjusting their treatment regimen. Immediate treatment for hypoglycemia usually involves consuming a rapid source of sugar, such as glucose tablets, juice, or candy, to quickly raise blood sugar levels back to normal range.
Neuroblastoma can be associated with paraneoplastic syndromes. All the following features are paraneoplastic EXCEPT
- A. uncontrollable jerking movements
- B. cerebellar ataxia and increased body coordination
- C. unilateral ptosis, myosis, and anhidrosis
- D. profound secretory diarrhea
Correct Answer: B
Rationale: Increased body coordination is not a typical feature of neuroblastoma-associated paraneoplastic syndromes.