Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:
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Solution
“This is only temporary; Stacy will re-grow new hair in 3-6 months but may be different in texture”.
Option D: This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture.
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician?
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Solution
“I will call my doctor if Stacy has persistent vomiting and diarrhea”.
Option B: Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the healthcare provider.
Options A, C, and D: The other manifestations are expected side effects of chemotherapy.
A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive?
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Solution
A Rh-negative
Option C: Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It’s important that a person with Rh-negative blood receives Rh-negative blood. If Rh-positive blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins, and subsequent transfusions with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood cells.
Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?
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Solution
Hodgkin’s disease
Option D: Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph node enlargement.
Option A: Influenza doesn’t last for months.
Option B: Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement.
Option C: Leukemia doesn’t cause lymph node enlargement.
An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?
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Solution
Low platelet count
Option A: In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin degradation products increase as fibrinolysis takes places.
Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?
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Solution
10 years
Option C: Epidemiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years.
The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system?
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Solution
Muscle spasm
Option B: Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as progression of the tumor may result in paraplegia.
Options A, C, and D: The other options, which reflect parts of the nervous system, aren’t usually affected by MM.
Francis with leukemia has neutropenia. Which of the following functions must be frequently assessed?
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Solution
Breath sounds
Option D: Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required.
Options A, B, and C: Although assessing blood pressure, bowel sounds, and heart sounds is important, it won’t help detect pneumonia.
The nurse is aware that the following symptom is most commonly an early indication of stage 1 Hodgkin’s disease?
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Solution
Night sweat
Option B: In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritus.
Option C: Although splenomegaly may be present in some clients, night sweats are generally more prevalent.
Option A: Pericarditis isn’t associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms.
Option D: Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease.
Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias?
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Solution
Essential thrombocytopenia
Option C: Essential thrombocytopenia is linked to immunologic disorders, such as SLE and human immunodeficiency virus.
Option D: The disorder known as von Willebrand’s disease is a type of hemophilia and isn’t linked to SLE.
Option B: Moderate to severe anemia is associated with SLE, not polycythemia.
Option A: Dressler’s syndrome is pericarditis that occurs after a myocardial infarction and isn’t linked to SLE.