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 B
Explanation
- A: An INR of 1.1 is within the normal range, indicating normal blood clotting ability, which is essential for wound healing. A normal INR does not pose a risk for delayed wound healing.
- B: Hyperemesis can lead to dehydration and malnutrition, both of which are detrimental to wound healing. Dehydration reduces blood volume and flow, impairing the delivery of oxygen and nutrients to the wound site, while malnutrition can weaken the immune response and the formation of new tissue.
- C: An HbA1C level of 5.6% is at the high end of the normal range and does not typically indicate diabetes or impaired glucose control, which are risk factors for delayed wound healing.
- D: While uncontrolled pain can be a concern for patient comfort and may indirectly affect wound healing by reducing mobility, it is not a direct risk factor for delayed wound healing like hyperemesis is.
Correct Answer is A
Explanation
A.
A. Edema is a common early sign of compartment syndrome as increased pressure within the compartment impairs venous outflow, leading to swelling.
B. Shortness of breath is not typically associated with compartment syndrome but may indicate other respiratory or cardiac issues.
C. Petechiae are not typically associated with compartment syndrome but may occur in conditions such as thrombocytopenia or coagulopathy.
D. Change in mental status is not typically associated with compartment syndrome but may indicate other neurological issues.
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