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

Answer and Explanation

The Correct Answer is B

A. Failure to engraft typically presents with symptoms such as persistent neutropenia, thrombocytopenia, and anemia, rather than skin peeling.

B. Veno-occlusive disease, also known as sinusoidal obstruction syndrome, can lead to liver dysfunction and subsequent skin manifestations such as peeling, especially on the palms and soles.

C. Graft-versus-host disease (GVHD) typically presents with symptoms such as skin rash, diarrhea, and liver dysfunction, but peeling skin is not a hallmark manifestation.

D. Pancytopenia refers to a deficiency of all types of blood cells (red blood cells, white blood cells, and platelets) and is not typically associated with skin peeling as a primary symptom.

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Correct Answer is B

Explanation

A. While a blood pressure of 156/90 mm Hg may be elevated, it is not necessarily an indication to withhold propranolol, which is commonly used to treat hypertension.

B. A pulse rate of 54/min suggests bradycardia, which is a potential side effect of propranolol and may warrant withholding the medication.

C. A potassium level of 5.2 mEq/L is within the normal range (3.5-5.0 mEq/L) and is not typically a reason to withhold propranolol.

D. A sodium level of 130 mEq/L is within the normal range (135-145 mEq/L) and is not typically a reason to withhold propranolol.

A. "Why do you think your life is not worth it anymore?" B. "You can trust me and tell me what you are thinking." C. "I need to know what you mean by misery." D. "Do you have a plan to end your life?"

Correct Answer is D

Explanation

A. This response may come across as confrontational and could potentially shut down further communication. It's important to offer support and empathy rather than immediately probing with questions.

B. While saying, "You can trust me and tell me what you are thinking," may foster trust, it is too vague and does not focus on assessing the client’s level of suicidal ideation or intent. Effective responses should prioritize safety by exploring specific details about the client’s thoughts.

C. "I need to know what you mean by misery" focuses on understanding the client’s emotional state but does not address the immediate concern of suicidal thoughts. While exploring the client’s feelings is important, it is secondary to assessing imminent risk.

D. Asking, "Do you have a plan to end your life?" is appropriate because it directly assesses the client’s risk for suicide. Determining whether the client has a specific plan, the means to carry it out, and intent to act is essential for evaluating the severity of the situation and implementing safety measures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication?

Correct Answer is B

Explanation

A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

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