Nokea
Which concepts could the nurse identify for a client diagnosed with lymphoma? Select all that apply.
- A. Coping.
- B. Hematologic regulation.
- C. Tissue perfusion.
- D. Clotting.
- E. Clinical judgment.
Correct Answer: A,B,C,D
Rationale: Lymphoma involves coping (A) with diagnosis, hematologic regulation (B) via lymph dysfunction, perfusion (C) due to node obstruction, and clotting (D) from thrombocytopenia. Clinical judgment (E) is a nursing process, not a patient concept.
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A coworker being oriented by another nurse states, “I’m confused; a physician told me that graft-versus-host disease (GVHD) symptoms were desirable for a particular client after a bone marrow transplant.” Which should be the nurse’s best response?
- A. “GVHD isn’t desirable. Maybe you heard the physician wrong.”
- B. “That’s interesting. Did the client have a gastrointestinal tumor?”
- C. “That’s right if the transplant involved using autologous stem cells.”
- D. “GVHD is sometimes desirable with a hematological malignancy.”
Correct Answer: D
Rationale: A. GVHD is desirable if the primary source is hematological. B. Bone marrow transplant is not a treatment for GI malignancies unless the primary source is hematological. C. GVHD does not occur when a person receives autologous (his or her own) cells during a transplant. D. GVHD is sometimes desirable with a hematological malignancy. The donor lymphocytes can mount a reaction against any lingering tumor cells and destroy them.
The nurse identified clotting as a concept related to sickle cell disease. Which intervention should the nurse implement?
- A. Assess for cerebrovascular symptoms.
- B. Keep the head of the bed elevated.
- C. Order a 2,000-mg sodium diet.
- D. Apply antiembolism stockings.
Correct Answer: A
Rationale: SCD causes vaso-occlusion; assessing cerebrovascular symptoms (A) detects stroke risk. HOB elevation (B) is for ICP, sodium diet (C) is for hypertension, and stockings (D) are for DVT.
The nurse receives orders after notifying an HCP about the client who has tachycardia, diaphoresis, and an elevated temperature after treatments for ALL. Which order should be the nurse’s priority?
- A. Portable chest x-ray in the client’s room
- B. Urine culture, and blood cultures x 2
- C. Vancomycin 500 mg IV q6h
- D. Filgrastim 0.3 mg subcut daily
Correct Answer: B
Rationale: A. The results of the portable CXR will help determine if the cause is a respiratory infection. It will not change the treatment. B. Urine and blood cultures are priority; these should be obtained before antibiotics are administered. C. National recommendations are to administer broad-spectrum antibiotics such as vancomycin (Vancocin) within 1 hour of a suspected infection diagnosis. The antibiotics may be changed after culture and sensitivity reports are available (usually 24 to 48 hours). D. It takes 4 days for filgrastim (Neupogen) to return the neutrophil count to baseline, so this is not priority. Filgrastim should not be given within 24 hours of cytotoxic chemotherapy.
The client diagnosed with leukemia has central nervous system involvement. Which instruction should the nurse teach?
- A. Sleep with the HOB elevated to prevent increased intracranial pressure.
- B. Take an analgesic medication for pain only when the pain becomes severe.
- C. Explain radiation therapy to the head may result in permanent hair loss.
- D. Discuss end-of-life decisions prior to cognitive deterioration.
Correct Answer: D
Rationale: CNS leukemia risks cognitive decline; discussing end-of-life decisions (D) is critical before deterioration. HOB elevation (A) is for ICP, not routine, analgesics (B) should be proactive, and hair loss (C) is secondary.
The client is diagnosed with chronic myeloid leukemia and leukocytosis. Which signs/symptoms would the nurse expect to find when assessing this client?
- A. Frothy sputum and jugular vein distention.
- B. Dyspnea and slight confusion.
- C. Right upper quadrant tenderness and nausea.
- D. Increased appetite and weight gain.
Correct Answer: B
Rationale: CML with leukocytosis causes fatigue, dyspnea, and confusion (B) from hyperviscosity. Sputum/JVD (A) suggest heart failure, RUQ/nausea (C) suggest liver issues, and appetite/weight gain (D) are unlikely.