A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications?
Failure to engraft
Veno-occlusive disease
Graft-versus-host disease
Pancytopenia
The Correct Answer is C
A. Failure to engraft is characterized by the absence of new bone marrow cell growth, leading to persistent low blood counts. It does not typically present with skin peeling or desquamation.
B. Veno-occlusive disease primarily affects the liver and presents with symptoms such as weight gain, hepatomegaly, and jaundice. Skin desquamation is not a common manifestation of this complication.
C. Graft-versus-host disease commonly affects the skin, liver, and gastrointestinal tract, with early signs including rash and desquamation of the hands and feet. This finding is a hallmark indication of this complication following a bone marrow transplant.
D. Pancytopenia involves a reduction in red blood cells, white blood cells, and platelets, leading to fatigue, infection risk, and bleeding. It does not typically cause skin peeling.
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Related Questions
Correct Answer is A
Explanation
A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.
B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.
C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.
D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.
Correct Answer is B
Explanation
A. Levothyroxine is a medication used to treat hypothyroidism by replacing or supplementing thyroid hormone. It is not typically associated with decreased blood pressure.
B. Weight loss can be an indicator that levothyroxine therapy is effective in treating hypothyroidism. Hypothyroidism often leads to weight gain, and successful treatment with levothyroxine can help reverse this trend.
C. Levothyroxine therapy primarily targets thyroid hormone levels and is not directly associated with decreased inflammation.
D. Seizures are not typically associated with hypothyroidism or its treatment with levothyroxine.
The effectiveness of levothyroxine is primarily assessed by monitoring thyroid function tests and clinical symptoms such as weight loss, improved energy levels, and resolution of hypothyroid symptoms.
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