Nokea
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: The correct answer is D: Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Thrombocytopenia is a low platelet count, which can lead to impaired blood clotting and potential bleeding. Ineffective tissue perfusion is the most critical concern as it can lead to life-threatening complications like hemorrhage. Activity intolerance, impaired tissue integrity, and impaired oral mucous membranes are important but do not pose an immediate threat to the client's life compared to the risk of hemorrhage from thrombocytopenia.
You may also like to solve these questions
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?
- A. White, cottage cheese-like patches on the
- B. Red, open sores on the oral mucosa
- C. Rust-colored sputum
- D. Yellow tooth discoloration
Correct Answer: B
Rationale: The correct answer is B because red, open sores on the oral mucosa are a common sign of stomatitis, which can be caused by chemotherapy. Stomatitis is characterized by inflammation and ulceration of the mouth lining. The other choices are incorrect because:
A: White, cottage cheese-like patches are indicative of oral thrush, a fungal infection.
C: Rust-colored sputum may indicate a respiratory condition or infection, not stomatitis.
D: Yellow tooth discoloration is not typically associated with stomatitis, but can be caused by various factors such as poor oral hygiene or certain foods.
A patient is being given penicillin via IV piggyback and develops an anaphylactic reaction. Which of the following should be the nurse’s first action?
- A. Call the doctor
- B. Maintain the antibiotic
- C. Call for help
- D. Turn off the antibiotic
Correct Answer: D
Rationale: The correct answer is D: Turn off the antibiotic. This should be the nurse's first action because in an anaphylactic reaction, stopping the administration of the causative agent is crucial to prevent further harm. Continuing the antibiotic (Choice B) can worsen the reaction. Calling the doctor (Choice A) may cause a delay in the immediate intervention needed. Calling for help (Choice C) is important but turning off the antibiotic takes precedence to stop the allergen.
A nurse caring for a patient with a herniated lumbar disk develops a plan of care for impaired mobility related to nerve compression. Which patient outcome indicates that the plan has been successful?
- A. The patient rates the pain at 3 to 4 on a 0 to 10 scale
- B. The patient has full ROM of the upper extremities
- C. The patient demonstrates correct self-administration of analgesics
- D. The patient is able to ambulate 25 feet without pain
Correct Answer: D
Rationale: The correct answer is D: The patient is able to ambulate 25 feet without pain. This outcome indicates successful plan implementation for impaired mobility due to nerve compression. Ambulating without pain shows improved mobility and nerve compression relief. Choices A, B, and C do not directly address mobility improvement. Choice A focuses on pain level, which is important but not a direct measure of mobility. Choice B refers to upper extremities, not the lower extremities affected by lumbar disk herniation. Choice C addresses medication management, not mobility improvement.
During the physical assessment, the nurse recalls that the areas most frequently affected by multiple sclerosis are the:
- A. Lateral, 3rd and 4th ventricles
- B. Pons medulla and cerebral peduncles
- C. Optic nerve and chiasm
- D. Above areas
Correct Answer: C
Rationale: Rationale for Choice C (Correct Answer):
1. Multiple sclerosis (MS) commonly affects the optic nerve and chiasm.
2. MS is characterized by demyelination of nerves, leading to visual disturbances.
3. Optic nerve involvement results in vision problems, such as blurred vision.
4. Chiasm involvement can cause visual field deficits and color perception changes.
Summary of Other Choices:
A: Lateral, 3rd, and 4th ventricles - Incorrect. MS primarily affects the central nervous system, not ventricles.
B: Pons, medulla, and cerebral peduncles - Incorrect. While these areas are part of the brainstem, they are not commonly affected in MS.
D: Above areas - Incorrect. This choice is vague and does not specify any specific areas affected by MS.
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on their own thoughts and identify potential causes of their fatigue. It allows the patient to express their own insights and helps the nurse understand the underlying reasons for the fatigue. Choice A focuses on stress, which may not be the main cause of fatigue. Choice C is irrelevant to exploring the fatigue further. Choice D assumes that lack of sleep is the main issue, which may not be the case for the patient.