Nokea
A patient reports severe abdominal cramping and diarrhea. Assessment reveals a temperature of 102°F (38.8°C) and pulse of 82 beats/min. Results of a complete blood count reveal lower than normal segmented and banded neutrophils and higher than normal lymphocytes. Which type of infection does the nurse suspect this patient is most likely experiencing?
- A. Viral
- B. Fungal
- C. Parasitic
- D. Bacterial
Correct Answer: A
Rationale: The correct answer is A: Viral. The patient's symptoms of abdominal cramping, diarrhea, fever, and altered white blood cell count with low neutrophils and high lymphocytes suggest a viral infection. Viral infections often present with these symptoms and characteristic lab findings. Other choices are incorrect because fungal infections typically do not cause acute abdominal symptoms, parasitic infections usually present with different symptoms and lab findings, and bacterial infections are more likely to have elevated neutrophils and different clinical presentation.
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A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the patient's care plan?
- A. Protective isolation and vigilant use of standard precautions
- B. Provision of a high-calorie, low-texture diet and appropriate oral hygiene
- C. Including the family in planning the patient's activities of daily living
- D. Monitoring and treating the patient's pain
Correct Answer: A
Rationale: The correct answer is A: Protective isolation and vigilant use of standard precautions. This is the priority because patients with AML are at high risk for infections due to compromised immune systems. Isolation and strict infection control measures help prevent exposure to pathogens. B is incorrect as the main priority is infection prevention, not diet. C is incorrect as involving the family is important but not the priority. D is incorrect as pain monitoring is important but not the priority in this case.
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 diagnoses?
- 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. During induction therapy for acute myeloid leukemia, the patient's immune system is compromised, making them highly susceptible to infections. Therefore, the highest priority nursing diagnosis should be addressing and preventing infections. This includes monitoring for signs of infection, implementing proper infection control measures, educating the patient and family on infection prevention, and administering prophylactic antibiotics as needed.
Choice A (Activity Intolerance) may be a concern due to the patient's underlying condition and treatment, but preventing infections takes precedence as it can lead to life-threatening complications. Choice C (Acute Confusion) and Choice D (Risk for Spiritual Distress) are important considerations but do not pose an immediate threat to the patient's health and safety compared to the risk of infection.
A nurse is caring for a client who is taking clopidogrel to prevent stent restenosis. The nurse should monitor the client for which of the following adverse reactions?
- A. Hyperuricemia
- B. Hyponatremia
- C. Lymphocytopenia
- D. Thrombocytopenia
Correct Answer: D
Rationale: The correct answer is D: Thrombocytopenia. Clopidogrel is an antiplatelet medication that works by preventing blood clots. Thrombocytopenia is a decrease in platelet count, which can lead to bleeding issues. Monitoring for thrombocytopenia is essential as it can be a potential adverse reaction of clopidogrel.
A: Hyperuricemia is not typically associated with clopidogrel.
B: Hyponatremia is not a common adverse reaction of clopidogrel.
C: Lymphocytopenia is not a common side effect of clopidogrel.
In summary, the nurse should monitor for thrombocytopenia as a potential adverse reaction when caring for a client taking clopidogrel.
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 diagnoses?
- 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. During induction therapy for acute myeloid leukemia, the patient's immune system is compromised, increasing the risk of infections. Priority is given to preventing infections to avoid complications. Activity Intolerance (A) may be a concern but is secondary to infection risk. Acute Confusion (C) may occur but is not as critical as preventing infections. Risk for Spiritual Distress (D) is important but addressing physical needs like infection prevention takes precedence for this patient population.
A 3-year-old boy is referred to you for evaluation of right leukocoria. Funduscopic examination under anesthesia reveals a large amelanotic mass occupying more than two-thirds of the vitreous space in his right eye, with massive retinal detachment, consistent with group E retinoblastoma. The left eye is normal. An MRI confirms the funduscopic findings and shows no extraocular disease. What is the most appropriate next step in the management of this child's disease?
- A. Enucleation
- B. Systemic chemotherapy
- C. Brachytherapy
- D. Needle biopsy
Correct Answer: A
Rationale: The most appropriate next step in the management of the child's retinoblastoma is enucleation (choice A). Enucleation, the surgical removal of the affected eye, is indicated when there is a large intraocular tumor with extensive retinal detachment, as in this case. Enucleation can provide local control of the disease and prevent systemic spread. It is considered the standard treatment for advanced retinoblastoma to prevent metastasis.
Systemic chemotherapy (choice B) is not the first-line treatment for advanced retinoblastoma with massive intraocular involvement. Brachytherapy (choice C) involves the placement of a radioactive source near the tumor, which may not be effective in this case of extensive intraocular disease. Needle biopsy (choice D) is not recommended as the primary management strategy due to the risk of seeding tumor cells outside the eye. Therefore, enucleation is the most appropriate next step in this scenario.