A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range:

Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]

Review need for pneumococcal vaccine.

Implement bleeding precautions.

Place the client in protective isolation.

Assess vital signs every 4 hours.

Answer and Explanation

The Correct Answer is C

C. An ANC of 500/mm3 (0.5 x 10/L) is indicative of severe neutropenia, which places the client at a significantly increased risk of developing infections due to the decreased ability of the immune system to fight off pathogens. Placing the client in protective isolation is essential to minimize the risk of exposure to infectious agents that could lead to severe infections
A. While reviewing the need for pneumococcal vaccine is important for preventing infections in immunocompromised clients, it may not be the most immediate priority in this scenario.
B. Implementing bleeding precautions is relevant for clients with thrombocytopenia but is not the most critical intervention for a client with severe neutropenia.
D. Assessing vital signs every 4 hours is a routine nursing intervention, but it may not directly address the heightened risk of infection associated with severe neutropenia.

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Correct Answer is B

Explanation

B. Severe edema is a common finding in venous insufficiency and is often present in the lower extremities. Venous hypertension leads to fluid leakage from capillaries, resulting in edema, which contributes to the development of venous ulcers. Venous ulcers typically have irregular shapes with irregular wound margins and may appear shallow or superficial.
A. Absent pedal pulses suggest arterial insufficiency, as reduced blood flow compromises peripheral circulation. Shiny skin, known as "thinning of the skin," is a characteristic finding in arterial insufficiency due to chronic ischemia and tissue hypoxia.
C. Hair loss on the lower extremities is a common finding in arterial insufficiency due to decreased blood flow to the hair follicles.
D. Black ulcers (gangrene) are indicative of tissue necrosis resulting from severe arterial insufficiency and lack of oxygen supply to the tissues. Dependent rubor refers to redness of the lower extremities when the legs are in a dependent position.

A. Exhibits angry outbursts when the subject of dying is approached. B. Increased intervals of sleep 18 out of 24 hours. C. A change has recently occurred in handwriting. D. Refuses to see friends or to return their phone calls.

Correct Answer is C

Explanation

C. One of the hallmark features of ADC is the development of cognitive impairment, including changes in memory, concentration, and problem-solving abilities. The change in handwriting (graphomotor impairment) is a specific neurological symptom that may indicate cognitive dysfunction and is consistent with the diagnosis of AIDS dementia.
A. This symptom suggests emotional distress or mood disturbances, which can occur in individuals with HIV/AIDS due to the psychological impact of the diagnosis and the uncertainty surrounding the disease progression. However, it is not specific to AIDS dementia
B. Increased sleepiness or hypersomnia can occur in individuals with AIDS dementia due to disruptions in sleep-wake cycles and alterations in brain function. However, increased sleepiness alone is not specific to AIDS dementia
D. Social withdrawal or isolation can occur in individuals with HIV/AIDS due to various reasons, including stigma, depression, or physical symptoms. However, it is not specific to AIDS dementia.

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A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range: Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a client with skin ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

Correct Answer is B

Explanation

A family suspects that AIDS dementia is occurring in their adult child who is HIV positive. Which symptom confirms the suspicion?

Correct Answer is C

Explanation

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize?

Five months following treatment for herpes zoster, an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range:

Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]