A nurse is caring for a client who has cancer and is undergoing chemotherapy.
Which of the following assessments indicates an improvement in the client's condition?
(Select all that apply.)
WBC count
Platelet count
Bleeding episodes
Oral health
Weight change
Correct Answer : C,D
A. In January, WBC count was 5,500/mm3. In February, it decreased to 4,500/mm3. A decrease in WBC count indicates worsening in the client's condition since they are prone to infections.
B. In January, platelet count was 150,000/mm3. In February, it decreased slightly to 140,000/mm3. The slight decrease in platelet count may not necessarily indicate improvement but is relatively stable.
C. In January, the client reported bleeding episodes from mouth ulcers. In February, the client reports no bleeding episodes. The absence of bleeding episodes indicates improvement in oral mucosal health and potential effectiveness of interventions.
D. In January, the oral mucosa was inflamed. In February, there is noted improvement with less inflammation. Improved oral health with reduced inflammation indicates a positive response to interventions and potentially better oral hygiene practices.
E. The client experienced weight loss of 1.5 kg (3.3 lb) from January to February. Weight loss may indicate ongoing challenges with nutrition despite efforts to increase food intake and manage symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sending blood to the lab for a complete blood count can wait until after immediate stabilization measures are initiated.
B. Finishing the primary survey is important, but the absent pulses and swollen leg suggest a critical vascular issue that needs immediate attention.
C. Assessing further for the cause of decreased circulation is the next step to determine if immediate intervention such as surgical consultation or revascularization is needed.
D. Starting normal saline infusion may be necessary later, but determining the cause of decreased circulation takes priority to prevent potential limb loss.
Correct Answer is B
Explanation
A. Developing atrial fibrillation can be a complication of hypothermia, but rewarming is still necessary to address the underlying condition.
B. Active rewarming should be discontinued if the patient's core temperature reaches 94°F (34.4°C), as further active rewarming could lead to complications. It's important to transition to passive rewarming methods to allow the patient's temperature to normalize gradually.
C. A decrease in blood pressure may indicate hypovolemia or shock but does not necessarily require discontinuation of rewarming.
D. Shivering is a normal response during rewarming and does not indicate a need to discontinue rewarming efforts unless other complications arise.
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