The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
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Solution
A large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs.
Option A: Measuring the urinary output is important, but the stem already says that the client has polyuria.
Option C: Encouraging fluid intake will not correct the problem.
Option D: Weighing the client is not necessary at this time.
A client with a pituitary tumor has had a transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client?
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Solution
Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. A, B, and D are incorrect
Options A, B, and D: Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, It will be most important to teach the client and family about:
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Solution
The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding.
Options B and D are of lesser priority and are incorrect in this instance.
Option C is important, but platelets do not carry oxygen.
A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
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Solution
Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer.
Options B, C, and D: White cell counts, potassium levels, and PTT are not affected in ATP.
A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
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Solution
Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early.
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
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Solution
The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem.
A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?
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Solution
The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months.
Options A, C, and D: Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations.
An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?
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Solution
Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petechiae.
Options A, B, and C: The skin in the abdomen, thorax, and earlobes might be too dark to make an assessment.
A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?
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Solution
Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia.
Option D: he incidence of leukemia is higher in twins than in siblings.
The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
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Solution
The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect.
Options B, C, and D: Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.