Nokea
A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
- A. Helping clients adjust to their appearance.
- B. Reassuring clients that this change is temporary.
- C. Referring clients to a reputable wig shop.
- D. Teaching measures to prevent scalp injury.
Correct Answer: D
Rationale: The correct answer is D: Teaching measures to prevent scalp injury. Alopecia makes the scalp more vulnerable to injury, so educating clients on protective measures is crucial. Choices A and B focus on emotional support and reassurance, which are important but secondary to physical safety. Referring clients to a wig shop (choice C) addresses appearance but does not directly address the physical risk associated with scalp vulnerability.
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A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnosis?
- A. Activity Intolerance
- B. Risk for Infection
- C. Acute Confusion
- D. Risk for Spiritual Distress
Correct Answer: B
Rationale: The correct answer is B: Risk for Infection. Induction therapy for acute myeloid leukemia suppresses the immune system, making the patient highly susceptible to infections due to neutropenia. Preventing infections is crucial in these patients to avoid complications. Activity Intolerance (Choice A) may be a concern, but infection prevention is of higher priority. Acute Confusion (Choice C) and Risk for Spiritual Distress (Choice D) are not the immediate priorities in this situation.
Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids which of the following in the care of this client?
- A. Elevating the knee gatch on the bed
- B. Assisting with range-of-motion leg exercises
- C. Removal of antiembolism stockings twice daily
- D. Checking placement of pneumatic compression boots
Correct Answer: A
Rationale: The correct answer is A. Elevating the knee gatch on the bed should be avoided in the care of a client who has undergone a vaginal hysterectomy. This action can inhibit venous return, increasing the risk of deep vein thrombosis or thrombophlebitis. Choices B, C, and D are appropriate nursing interventions for postoperative care to prevent complications and promote circulation.
A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy?
- A. Administer an antiemetic.
- B. Administer an antimetabolite.
- C. Administer a tumor antibiotic.
- D. Administer an anticoagulant.
Correct Answer: A
Rationale: The correct answer is A: Administer an antiemetic. Chemotherapy commonly causes nausea and vomiting as adverse effects. Antiemetics are medications specifically used to prevent or treat these symptoms. Choices B, C, and D are incorrect because administering an antimetabolite, a tumor antibiotic, or an anticoagulant would not directly address the most common adverse effects of chemotherapy, which are nausea and vomiting.
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?
- A. I should avoid blowing my nose.
- B. I may need a platelet transfusion if my platelet count is too low.
- C. I should take aspirin for my headache as soon as I get home.
- D. I will count the number of pads and tampons I use when menstruating.
Correct Answer: C
Rationale: The correct answer is C. Taking aspirin is not recommended during periods of bone marrow suppression as it can increase the risk of bleeding. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can impair platelet function, further exacerbating the risk of bleeding. Choices A, B, and D are all appropriate statements for a client at risk for bleeding and undergoing chemotherapy. Blowing the nose gently, being prepared for a platelet transfusion if needed, and monitoring menstrual bleeding are all important aspects of self-care during this period.
When working with clients experiencing alopecia, what is the best method for a nurse to help them manage the psychosocial impact of this issue?
- A. Assisting the client in pre-planning for this event.
- B. Reassuring the client that alopecia is temporary.
- C. Teaching the client ways to protect the scalp.
- D. Telling the client that there are worse side effects.
Correct Answer: A
Rationale: Assisting the client in pre-planning for alopecia is the best method to help them manage the psychosocial impact of the issue. By helping clients anticipate and prepare for the challenges associated with alopecia, they can cope better with the psychological impact. Reassuring the client that alopecia is temporary (choice B) may provide false hope as some types of alopecia are permanent. Teaching ways to protect the scalp (choice C) is important but not the most effective method for managing the psychosocial impact. Telling the client that there are worse side effects (choice D) is dismissive of the client's feelings and not helpful in addressing the psychosocial impact of alopecia.