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

Explanation

Choice A rationale
Muscle wasting and osteoporosis are common findings in Cushing's syndrome due to prolonged exposure to high levels of cortisol, which leads to the breakdown of muscle tissue and decreases in bone density.
Choice B rationale
Diaphoresis is not a typical feature of Cushing's syndrome. While excessive sweating can occur in various conditions, it is not a hallmark of Cushing's syndrome, which primarily affects muscle, bone, and fat distribution.
Choice C rationale
Hypotension is not characteristic of Cushing's syndrome. Instead, hypertension is more common due to cortisol's effects on increasing blood pressure through sodium and water retention.
Choice D rationale
Weight loss is not a typical finding in Cushing's syndrome. Individuals with Cushing's syndrome often experience weight gain, particularly around the abdomen, face, and neck, due to cortisol's effects on fat distribution.

A. A raised rash across the nose and face. B. Hypothermia. C. Weight gain. D. Muscle hyperreflexia.

Correct Answer is A

Explanation

Choice A rationale
A raised rash across the nose and face, known as a butterfly rash, is a classic and distinctive manifestation of systemic lupus erythematosus (SLE), often exacerbated by sunlight exposure.
Choice B rationale
Hypothermia is not a common manifestation of SLE; patients more frequently experience fevers due to inflammation and immune system dysregulation.
Choice C rationale
Weight gain is not a typical direct manifestation of SLE; patients might experience weight changes due to medications or complications but not as a primary symptom.
Choice D rationale
Muscle hyperreflexia is not associated with SLE; neurological symptoms in SLE might include seizures or cognitive dysfunction, but not hyperreflexia.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is preparing a presentation at a community center about systemic lupus erythematosus (SLE). The nurse should plan to include which of the following findings as a manifestation of SLE?

Correct Answer is A

Explanation

A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?

A nurse is admitting a child who has a total WBC count of 1200. Which of the following clients should the nurse place in the same room with this child?

A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer.Which of the following actions should the nurse plan to take?

A nurse is caring for a client who asks to be screened for cervical cancer because a relative has been diagnosed with it. Which of the following tests should the nurse expect the provider to use?

A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE) and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body?

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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.)

A nurse is planning to assign tasks for a group of clients.Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply)