A nurse is caring for an adult client receiving chemotherapy for acute leukemia on the medical-surgical unit. The client reports chills and weakness. Which interpretation by the nurse is most accurate?
The client is demonstrating neutropenic sepsis with septic shock
The client is experiencing tumor lysis syndrome
The client is showing expected chemotherapy-related fatigue
The client is developing superior vena cava syndrome
The Correct Answer is A
Identifying life-threatening complications in immunocompromised oncology patients requires synthesizing laboratory data with clinical symptoms. Knowledge of systemic inflammatory response syndrome, cellular metabolism under stress, and neutropenia thresholds is essential to differentiate between expected chemotherapy side effects and the onset of acute septic shock.
Choice A rationale: An ANC of 400/mm³ signifies severe neutropenia (normal ≥ 1500/mm³), increasing vulnerability to infection. Combined with chills and a lactate of 5.6 mmol/L (normal ≤ 2.0 mmol/L), which indicates tissue hypoperfusion and anaerobic metabolism, the client meets criteria for septic shock.
Choice B rationale: Tumor lysis syndrome involves metabolic disturbances including hyperkalemia, hyperuricemia, and hyperphosphatemia resulting from rapid cancer cell death. While common in leukemia treatment, it does not typically present with severe lactic acidosis and sepsis symptoms like chills and extreme neutrophil depletion.
Choice C rationale: While chemotherapy-related fatigue is a standard expectation, it is a diagnosis of exclusion. Attributing a high lactate level and clinical instability to mere fatigue is a dangerous misinterpretation that ignores the objective evidence of physiological distress and cellular hypoxia.
Choice D rationale: Superior vena cava syndrome is an obstructive emergency characterized by facial edema, distended neck veins, and upper body redness due to blood flow blockage. It does not correlate with the metabolic lactic acidosis or the hematologic findings of neutropenia seen here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This clinical presentation requires applying knowledge of Monro-Kellie doctrine and neurological assessment. Understanding how space-occupying lesions like brain tumors affect intracranial dynamics is vital for identifying life-threatening shifts in pressure that manifest as headache, projectile vomiting, and mental status changes.
Choice A rationale
Migraine headaches typically present with unilateral throbbing pain and photophobia but rarely cause sudden, severe altered consciousness in this context. While painful, they do not explain the acute neurological decline associated with a known intracranial tumor.
Choice B rationale
Dehydration usually presents with tachycardia, poor skin turgor, and hypotension. While it can cause lightheadedness or confusion in extreme cases, it does not typically cause the sudden onset of a severe headache and vomiting seen in neurological emergencies.
Choice C rationale
Increased intracranial pressure results from the tumor mass or associated edema. It compresses brain tissue and blood vessels, leading to the classic triad of headache, vomiting, and altered consciousness, signaling a potential brain herniation and neurological crisis.
Choice D rationale
A gastric ulcer causes epigastric pain and potentially hematemesis if perforated. While vomiting may occur, it is unrelated to sudden neurological changes or severe headaches. This diagnosis fails to address the primary intracranial pathology and accompanying mental deficits.
Correct Answer is A
Explanation
Pyloric obstruction involves a mechanical blockage at the stomach outlet, leading to the accumulation of gastric contents. Knowledge of gastrointestinal decompression and the therapeutic purpose of nasogastric tubes in managing increased intragastric pressure and preventing emesis is required here.
Choice A rationale
Pyloric obstruction causes gastric stasis and distension because contents cannot enter the duodenum. Nasogastric intubation provides decompression by removing accumulated secretions and gas, which relieves pressure, prevents vomiting, and reduces the risk of aspiration in the client.
Choice B rationale
Providing nutrition via tube feeding is contraindicated in pyloric obstruction. Because the outlet of the stomach is blocked, any enteral formula introduced would accumulate in the stomach, worsening distension and significantly increasing the risk of reflux or aspiration.
Choice C rationale
While gastric pH can be measured via a nasogastric tube, it is not the primary therapeutic rationale for tube placement in a client with a mechanical obstruction. Decompression is a critical intervention to ensure safety and comfort.
Choice D rationale
Administering oral medications through a nasogastric tube is ineffective during an obstruction. The medication cannot pass the pylorus to be absorbed in the small intestine, and it adds volume to an already overfilled and pressurized stomach.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.