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The client is diagnosed with chronic lymphocytic leukemia (CLL) after routine laboratory tests during a yearly physical. Which is the scientific rationale for the random nature of discovering the illness?
- A. CLL is not serious, and clients die from other causes first.
- B. There are no symptoms with this form of leukemia.
- C. This is a childhood illness and is self-limiting.
- D. In early stages of CLL, the client may be asymptomatic.
Correct Answer: D
Rationale: Early CLL is often asymptomatic (D), detected via routine labs. CLL is serious (A), has symptoms later (B), and is adult-onset (C), not self-limiting.
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The nurse is assessing the client newly diagnosed with endometrial cancer. Which common findings would the nurse expect?
- A. Abnormal vaginal bleeding and pain in the pelvic area
- B. Weight loss and profuse sweating, especially at night
- C. Anorexia and enlarged supraclavicular lymph nodes
- D. Unexplained spikes in temperature and splenomegaly
Correct Answer: A
Rationale: A. Abnormal vaginal bleeding and pain in the pelvic region appear as the most common presenting symptoms in the client with endometrial cancer. B. Weight loss is not a common presenting symptom unless the cancer is advanced. Night sweats may occur with hormone changes. C. Supraclavicular lymph nodes are located just above the clavicle, lateral to where it joins the sternum, and not near the uterus. D. Unexplained temperature spikes and splenomegaly are not common presenting symptoms.
The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first?
- A. The client who is two-thirds of the way through a blood transfusion and has no complaints of dyspnea or hives.
- B. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body.
- C. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood.
- D. The client diagnosed with Crohn’s disease who is complaining of perineal discomfort.
Correct Answer: C
Rationale: Vomiting blood (C) indicates active GI bleeding, a life-threatening emergency. Low Hct/petechiae (B) is urgent but stable, transfusion (A) is uneventful, and perineal discomfort (D) is least urgent.
The nurse is assessing an African American client diagnosed with sickle cell crisis. Which assessment datum is most pertinent when assessing for cyanosis in clients with dark skin?
- A. Assess the client’s oral mucosa.
- B. Assess the client’s metatarsals.
- C. Assess the client’s capillary refill time.
- D. Assess the sclera of the client’s eyes.
Correct Answer: A
Rationale: Oral mucosa (A) is the best site to assess cyanosis in dark skin, showing dusky color. Metatarsals (B) and sclera (D) are less reliable, and capillary refill (C) assesses perfusion.
The nurse is caring for the following clients. Which client should the nurse assess first?
- A. The client whose partial thromboplastin time (PTT) is 38 seconds.
- B. The client whose hemoglobin is 14 g/dL and hematocrit is 45%.
- C. The client whose platelet count is 75,000 per cubic millimeter of blood.
- D. The client whose red blood cell count is 4.8 x 106/mm3.
Correct Answer: C
Rationale: Platelets 75,000 (C) indicate thrombocytopenia, risking bleeding, a priority. PTT 38 (A) is therapeutic, Hb/Hct (B) are normal, and RBC 4.8 (D) is normal.
The nurse is teaching self-care measures to the client hospitalized with HP. Which measures should the nurse plan to include?
- A. “Use dental floss daily after brushing your teeth.”
- B. “Use only an electric razor when you need to shave.”
- C. “Remove throw rugs in your home and avoid clutter.”
- D. “Increase fiber in your diet and drink plenty of liquids.”
- E. “Keep appointments for monthly platelet transfusions.”
Correct Answer: B, C, D
Rationale: Dental floss can traumatize the gums and increase the risk for bleeding. B. Because the client is at risk for bleeding due to low platelet counts, measures to decrease the risk of bleeding should be implemented, such as using an electric razor. C. Throw rugs and clutter increase the risk for falls with subsequent bleeding. D. Fiber and fluids help prevent constipation. Constipation can lead to hemorrhoids and increase the risk for bleeding. E. Platelet transfusions are usually avoided because the person’s antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed.