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The nurse is caring for a client who is receiving chemotherapy. Which laboratory result indicates that the client is at risk for infection?
- A. Hemoglobin level of 12 g/dL.
- B. Platelet count of 150,000/mm3.
- C. White blood cell count of 2,000/mm3.
- D. Serum creatinine level of 1.0 mg/dL.
Correct Answer: C
Rationale: The correct answer is C: White blood cell count of 2,000/mm3. A low white blood cell count indicates leukopenia, which increases the risk of infection in clients receiving chemotherapy. Hemoglobin level (choice A) and platelet count (choice B) are not directly related to infection risk. Serum creatinine level (choice D) is related to kidney function, not infection risk. In summary, a low white blood cell count is the most critical indicator for infection risk in clients undergoing chemotherapy.
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When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?
- A. Brudzinski's sign
- B. Positive Babinski reflex
- C. Kernig's sign
- D. Both A and C
Correct Answer: D
Rationale: The correct answer is D, Both A and C. Brudzinski's sign and Kernig's sign are both indicative of meningeal irritation. Brudzinski's sign is when flexion of the neck causes involuntary flexion of the hip and knee. Kernig's sign is when there is resistance or pain with knee extension after hip flexion. These signs suggest inflammation of the meninges, commonly seen in meningitis. Babinski reflex (choice B) is not specific to meningitis and is related to upper motor neuron dysfunction. Therefore, the correct answer is D as it includes the two most relevant signs for meningeal irritation, while the other choices are not directly associated with this condition.
During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?
- A. Obtain a detailed substance use history.
- B. Establish a trusting nurse-client relationship.
- C. Evaluate the client's physical health status.
- D. Determine the client's readiness for change.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.
The nurse is planning care for a 16-year-old with juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscles. Which physical therapy regimen should the nurse encourage the adolescent to implement?
- A. Exercise in a swimming pool.
- B. Splint affected joints during activity.
- C. Perform passive range of motion exercises twice daily.
- D. Begin a training program of lifting weights and running.
Correct Answer: A
Rationale: The correct answer is A: Exercise in a swimming pool. This option is ideal for a 16-year-old with JRA because it provides a low-impact environment that helps strengthen muscles and improve joint mobility without putting excessive stress on the joints. Swimming also helps reduce pain and stiffness associated with JRA.
Choice B (Splint affected joints during activity) is incorrect because splinting may restrict movement and hinder muscle strengthening. Choice C (Perform passive range of motion exercises twice daily) is not as effective as active exercises in improving muscle strength and joint mobility. Choice D (Begin a training program of lifting weights and running) can be too high-impact and may exacerbate joint inflammation and pain in individuals with JRA.
A client with chronic kidney disease (CKD) is scheduled for a renal biopsy. Which pre-procedure instruction should the nurse provide?
- A. Maintain a low-protein diet for 24 hours before the biopsy.
- B. Avoid taking anticoagulant medications for one week before the biopsy.
- C. Drink plenty of fluids before the procedure.
- D. Take your routine medications with a full glass of water before the biopsy.
Correct Answer: B
Rationale: The correct answer is B: Avoid taking anticoagulant medications for one week before the biopsy. This is essential to prevent excessive bleeding during and after the procedure. Chronic kidney disease patients are at higher risk of bleeding due to impaired kidney function.
A: Maintaining a low-protein diet is not directly related to the biopsy procedure and is not necessary.
C: Drinking plenty of fluids may be beneficial for renal function but is not a specific pre-procedure instruction for a renal biopsy.
D: Taking routine medications with water is important, but specific instructions regarding anticoagulant medications are more critical in this case.
The healthcare provider is caring for a client with Guillain-Barr© syndrome. Which assessment finding requires the healthcare provider's immediate action?
- A. Loss of deep tendon reflexes.
- B. Ascending weakness.
- C. New onset of confusion.
- D. Decreased vital capacity.
Correct Answer: D
Rationale: The correct answer is D: Decreased vital capacity. This finding indicates respiratory muscle weakness, which can lead to respiratory failure in Guillain-Barr© syndrome. Immediate action is needed to prevent respiratory compromise. Choice A is a common finding in Guillain-Barr© and does not require immediate action. Choice B is characteristic of Guillain-Barr© and should be monitored but not the most urgent. Choice C could indicate other issues but is not as critical as respiratory compromise.