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The female client, who has Hodgkin’s lymphoma with cervical and axillary node involvement, is to receive chemotherapy and radiation. The nurse evaluates that the client is coping positively when the client makes which statement?
- A. “I’ve a wig that matches my hair color, but I’ll miss my own hair.”
- B. “I am so glad that the treatments won’t cause me to lose my hair.”
- C. “I’m happy that the drug-radiation combination prevents mucositis.”
- D. “I’ve faith that my doctor will cure me and I’ll never have cancer again.”
Correct Answer: A
Rationale: A. The client is expressing feelings about hair loss but has acted positively related to her feelings and obtained a wig. This statement indicates positive coping. B. This statement reflects that either the client is in denial or is uninformed regarding the effects of chemotherapy and radiation treatments. Chemotherapy and radiation will involve the cervical lymph nodes; side effects will include alopecia. C. Chemotherapy and radiation will involve the cervical lymph nodes; side effects will include mucositis. D. The risk for other cancers is increased after chemotherapy and radiation for Hodgkin’s lymphoma, so long-term surveillance is crucial.
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The nurse is caring for a client diagnosed with sickle cell disease. Which should the nurse include in the client’s plan of care?
- A. Teach the client to limit fluids.
- B. Discuss interventions to maintain hydration.
- C. Measure the client’s calf for swelling.
- D. Have the client take narcotic pain medication every four (4) hours.
Correct Answer: B
Rationale: Hydration (B) prevents sickling in SCD. Limiting fluids (A) worsens crisis, calf swelling (C) is for DVT, and scheduled narcotics (D) risk dependency.
The nurse is caring for a child who has hemophilia. He is admitted with a bleeding episode. Which of the following should the nurse expect will be given to stop the bleeding?
- A. Heparin
- B. Cryoprecipitate
- C. Packed cells
- D. Whole blood
Correct Answer: B
Rationale: Cryoprecipitate contains clotting factors, such as factor VIII, essential for stopping bleeding in hemophilia.
The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis?
- A. Fever and infections.
- B. Nausea and vomiting.
- C. Excessive energy and high platelet counts.
- D. Cervical lymph node enlargement and positive acid-fast bacillus.
Correct Answer: A
Rationale: AML causes neutropenia, leading to fever/infections (A). Nausea (B) is nonspecific, high platelets/energy (C) are incorrect (AML causes thrombocytopenia/fatigue), and acid-fast bacillus (D) indicates TB, not AML.
The charge nurse is making assignments on a medical floor. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with iron-deficiency anemia who is prescribed iron supplements.
- B. The client diagnosed with pernicious anemia who is receiving vitamin B12 intramuscularly.
- C. The client diagnosed with aplastic anemia who has developed pancytopenia.
- D. The client diagnosed with renal disease who has a deficiency of erythropoietin.
Correct Answer: C
Rationale: Aplastic anemia with pancytopenia (C) is complex, risking bleeding/infection, requiring experienced care. Iron (A), B12 (B), and renal anemia (D) are more stable.
The nurse is caring for the client placed on neutropenic precautions. Which interventions should the nurse implement?
- A. Apply pressure for at least 5 minutes to any site that is bleeding.
- B. Prevent anyone from bringing fresh flowers into the client’s room.
- C. Teach the client to avoid eating unwashed fruit and vegetables.
- D. Perform hand hygiene before touching any of the client’s belongings.
- E. Inform the client that fresh water will be delivered every hour.
- F. Stop visitors from entering the room if observed to be coughing.
Correct Answer: B, C, D, F, A.
Rationale: Pressure should be applied to an area that is bleeding when the client has thrombocytopenia, not neutropenia. B. Fresh flowers harbor microorganisms that can cause an infection. C. Unwashed fruits and vegetables have been found to be colonized with various bacteria, particularly gram-negative enteric organisms, as well as pseudomonas and fungi. Recent research indicates that well-washed fresh fruits and vegetables may be eaten. D. Hand hygiene reduces microbial counts on hands and helps to prevent the transmission of microorganisms to the client’s belongings. E. The client should not consume any liquids that have been standing at room temperature for longer than an hour due to risk of microbial colonization. F. Visitors with a transmittable infection place the client at a high risk for becoming infected due to the client’s depressed immune system.