A nurse is caring for a 63-year-old female client in the emergency department (ED) with a history of colorectal cancer. The client is receiving chemotherapy and radiation. She presents with complaints of fatigue, unexplained bruising, and recurring headaches. The nurse must evaluate the situation based on the exhibits provided to determine the client’s risk factors and findings.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Choice A rationale:
The client's low platelet count (90 x 10⁹/L) is a significant risk factor for developing Disseminated Intravascular Coagulation (DIC), a condition characterized by abnormal blood clotting and bleeding. The client's history of cancer and symptoms such as unexplained bruising and fatigue further support this risk.
Choice B rationale:
Hyperkalemia is characterized by high potassium levels, but the client's potassium level is within the normal range (4.1 mmol/L), so this is not a risk factor.
Choice C rationale:
Hyponatremia is a condition of low sodium levels in the blood. The client's sodium level is normal (137 mmol/L), so this is not a risk factor.
Choice D rationale:
Pneumonia is a lung infection, and the client's oxygen saturation is normal (98% on room air), indicating no immediate risk of pneumonia.
Choice E rationale:
Acute nephritic syndrome is a kidney disorder that can cause elevated blood urea nitrogen (BUN) and creatinine levels. The client's BUN is slightly elevated (22 mg/dL), but her creatinine level is normal (1.0 mg/dL), making this less likely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale: Oral health indicates the absence of mucositis or other oral complications, which is good, but it doesn't necessarily reflect overall improvement in the client's cancer or chemotherapy response.
Choice B rationale: The absence of bleeding episodes is significant. This suggests that the client's platelet count has improved, reducing the risk of bleeding, which is an important indicator of recovery.
Choice C rationale: While weight maintenance or gain can be an indicator of health improvement, the slight decrease in weight from January to February (70.5 kg to 69 kg) does not suggest an improvement.
Choice D rationale: An increase in the WBC count to within the normal range (4.2 x 10⁹/L) is a positive sign. It indicates that the client’s immune system is recovering, which is crucial during chemotherapy.
Choice E rationale: The improvement in platelet count to within the normal range (150 x 10⁹/L) suggests a reduced risk of bleeding and reflects better bone marrow function, which is a positive outcome of the treatment.
Correct Answer is D
Explanation
Choice A rationale
Joint pain in hands and knees is a common symptom of SLE due to inflammation but is not immediately life-threatening. It requires management but is not the highest priority.
Choice B rationale
A dry, raised rash on the face, such as a malar rash, is common in SLE and should be monitored and treated, but it is not immediately life-threatening.
Choice C rationale
Feelings of depression are serious and need addressing but are not an immediate threat to physical health. Depression is often associated with chronic illnesses and requires comprehensive mental health support.
Choice D rationale
Presence of peripheral edema could indicate renal involvement or cardiac issues in SLE, which can be life-threatening. It is crucial to address this finding urgently to prevent complications such as renal failure or severe cardiovascular events.
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