A nurse is caring for a 33-year-old male client in the oncology unit who was recently diagnosed with multiple myeloma. The client is currently receiving an induction chemotherapy protocol consisting of vincristine, dexamethasone, L-asparaginase, and anthracycline. The nurse must evaluate the client's condition based on the exhibits provided to determine appropriate actions and parameters to monitor.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale for correct condition: Mucositis is a common side effect of chemotherapy that causes inflammation and soreness in the mouth. The client reports mouth soreness and dry mucous membranes, consistent with mucositis. The presence of mild erythema on the oral mucosa also supports this diagnosis. Chemotherapy drugs such as vincristine and anthracycline are known to cause mucositis. Addressing mucositis early is crucial for maintaining the client’s nutrition and hydration.

Rationale for actions: Providing a soft sponge toothbrush helps maintain oral hygiene without causing further irritation. Maintaining the client’s diet ensures adequate nutrition, which is essential for healing mucositis. Pad the siderails of the bed is unnecessary in this scenario, as there's no indication of seizure risk. Requesting an antiemetic is irrelevant since the client has no significant nausea or vomiting.

Rationale for parameters: Monitoring weight loss helps assess the client’s nutritional status and the effectiveness of dietary interventions. Tracking intake and output ensures the client is adequately hydrated and that oral intake is sufficient. Edema monitoring is unnecessary, as there's no sign of fluid retention. Steatorrhea is not relevant in this context, as there's no indication of fat malabsorption.

Rationale for incorrect conditions: Diarrhea is not indicated as the client’s primary complaint is mouth soreness, not gastrointestinal upset. Angioedema is characterized by swelling and is not observed in the client. Seizures are not relevant here, as the client shows no neurological signs suggestive of seizure activity.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale
Immunosuppressed clients are at increased risk for infections from foodborne pathogens. Eating only cooked foods helps to kill potentially harmful bacteria, reducing the risk of infection. Raw foods can harbor bacteria and parasites that cooked foods do not.
Choice B rationale
Wearing a mask, gloves, and gown protects both the immunosuppressed client and the healthcare provider from the transmission of pathogens. This personal protective equipment (PPE) barrier reduces the likelihood of infection by preventing the transfer of pathogens.
Choice C rationale
Visitors with active infections pose a high risk to immunosuppressed clients due to their weakened immune systems. Restricting such visitors helps in minimizing the exposure to infectious agents and therefore decreases the risk of infections.
Choice D rationale
Incorrect, as disposing of linen in the trash is not a standard infection control practice. Linens should be handled according to hospital protocols, typically involving proper laundering to prevent contamination and spread of infections.
Choice E rationale
Limiting bathing is not recommended. Regular bathing helps in maintaining skin integrity and preventing skin infections. However, excessive bathing might lead to dry skin, so balanced hygiene practices should be maintained.

A. Assess for neck vein distention. B. Monitor for an irregular heart rate. C. Assess blood glucose level. D. Monitor for postural hypotension. E. Weigh the client daily.

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale
Assessing for neck vein distention helps monitor fluid overload, which is common in Cushing's syndrome due to cortisol's effects on fluid retention.
Choice B rationale
Monitoring for an irregular heart rate is important because cortisol can cause electrolyte imbalances and hypertension, which may affect heart rhythm.
Choice C rationale
Assessing blood glucose levels is essential since Cushing's syndrome can cause hyperglycemia due to cortisol's effects on glucose metabolism.
Choice D rationale
Monitoring for postural hypotension helps manage potential complications from cortisol's effects on blood pressure regulation.
Choice E rationale
Weighing the client daily is important for monitoring fluid retention and weight changes associated with Cushing's syndrome.

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Naxlex Comprehensive Predictor Exams

A nurse is creating the plan of care for a client who is immunosuppressed.Which of the following precautions should the nurse include in the plan? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

A nurse is caring for a client who has Cushing's syndrome.Which of the following interventions should the nurse expect to perform? (Select all that apply.)

Correct Answer is ["A","B","C","D","E"]

Explanation

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