Nokea
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.
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The client’s nephew has just been diagnosed with sickle cell anemia (SCA). The client asks the nurse, 'How did my nephew get this disease?' Which statement would be the best response by the nurse?
- A. Sickle cell anemia is an inherited autosomal recessive disease.'
- B. He was born with it and both his parents were carriers of the disease.'
- C. At this time, the cause of sickle cell anemia is unknown.'
- D. Your sister was exposed to a virus while she was pregnant.'
Correct Answer: A
Rationale: SCA is an autosomal recessive disorder (A), the most precise explanation. Parents as carriers (B) is partial, cause is known (C), and viral exposure (D) is incorrect.
The client is placed on neutropenia precautions. Which information should the nurse teach the client?
- A. Shave with an electric razor and use a soft toothbrush.
- B. Eat plenty of fresh fruits and vegetables.
- C. Perform perineal care after every bowel movement.
- D. Some blood in the urine is not unusual.
Correct Answer: A
Rationale: Neutropenia precautions include electric razors and soft toothbrushes (A) to prevent bleeding/infection. Fresh produce (B) risks infection, perineal care (C) is routine, and hematuria (D) is abnormal.
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.
The client diagnosed with sickle cell anemia asks the nurse, 'Why should I take those shots? I hate shots.' Which statement by the nurse is the best response?
- A. These vaccines promote health in clients with chronic illnesses.'
- B. You are susceptible to infections. These shots may help prevent a crisis.'
- C. The vaccines will help your blood from sickling secondary to viruses.'
- D. The doctor wanted to make sure that I discussed the vaccines with you.'
Correct Answer: B
Rationale: Flu/pneumonia vaccines (B) reduce infection risk, a common SCA crisis trigger. General health (A) is vague, sickling (C) is indirect, and HCP mention (D) avoids explanation.
The nurse is caring for the client receiving combination chemotherapy of oxaliplatin, fluorouracil, and leucovorin. The nurse should assess the client for which common side effects of this chemotherapy regimen?
- A. Neurotoxicities and diarrhea
- B. Cardiomyopathy and dysphagia
- C. Renal insufficiency and gastritis
- D. Photophobia and stomatitis
Correct Answer: A
Rationale: A. Neurotoxicity and diarrhea occur frequently in clients receiving the medication regimen of oxaliplatin (Eloxatin), fluorouracil (5-FU), and leucovorin (Wellcovorin). B. Cardiomyopathy and dysphagia are not common side effects of these chemotherapy agents. C. Renal insufficiency and gastritis are not common side effects of these chemotherapy agents. D. Photophobia and stomatitis are not common side effects of these chemotherapy agents.