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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Adequate hydration helps maintain skin integrity and reduces the risk of pressure injuries by keeping the skin hydrated and resilient.
B. Moisturizing dry skin is important for overall skin health but may not directly prevent pressure injuries.
C. While maintaining a comfortable room environment is important for the client's overall well- being, a dehumidifier specifically may not directly prevent pressure injuries.
D. Donut ring pillows are not recommended for pressure injury prevention as they can actually increase pressure on vulnerable areas of the skin, leading to tissue damage.
Correct Answer is C
Explanation
A. Holding the newborn in an en face position: This action promotes bonding between the mother and the newborn and is a positive interaction.
B. Asking the father to change the newborn's diaper: Involving the father in caregiving tasks fosters family involvement and bonding.
C. Viewing the newborn's actions to be uncooperative: This suggests a negative perception of the newborn's behavior, which could indicate potential issues with bonding or misunderstanding
infant cues, requiring the nurse's intervention.
D. Requesting the nurse take the newborn to the nursery so she can rest: While rest is important for the mother, separating the newborn from the mother could disrupt bonding and breastfeeding, so this action should be discussed further with the client to explore other options.
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