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 A

Explanation

A. Using a cell phone on the ear opposite to the pacemaker helps minimize the risk of electromagnetic interference with the pacemaker function.

B. Engaging in activities such as playing softball may not be appropriate immediately after pacemaker insertion. The client should follow specific activity restrictions as advised by the healthcare provider.

C. While performing arm exercises is generally beneficial for overall health, the client should avoid strenuous activities that may strain the upper body or disrupt the pacemaker leads

immediately after insertion.

D. Pacemaker battery replacement is typically scheduled based on the device's longevity and is performed in a healthcare facility, not the cardiologist's office. The client should follow up regularly with the healthcare provider for device checks and monitoring of battery status.

A. "Report the incident to Adult Protective Services." B. "Interview the client with his adult child present." C. "Tell the client he must answer every assessment question." D. "Advise the client to consult a social worker."

Correct Answer is A

Explanation

A. "Reporting the incident to Adult Protective Services" is crucial when there are signs of elder abuse or neglect. This action ensures that appropriate interventions are initiated to protect the client.

B. "Interviewing the client with his adult child present" may not allow the client to speak freely, especially if the adult child is the perpetrator or involved in the abuse. Confidentiality and safety are essential considerations.

C. "Telling the client he must answer every assessment question" can be intimidating and may not facilitate open communication, especially in situations involving abuse.

D. "Advising the client to consult a social worker" may be appropriate after reporting the incident to Adult Protective Services, but it is not the initial action to take when abuse is suspected. Reporting to authorities is the priority to ensure the client's safety.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

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