A nurse is creating a plan of care for a client who has cancer and is experiencing Immunosuppression. Which of the following Interventions should the nurse include in the plan of care?
Monitor the client's vital signs every 12 hr.
Inspect the client's mouth every 8 hr.
Provide fresh fruit with the client's meals.
Rotate health care staff caring for the client.
The Correct Answer is B
A. Monitoring vital signs every 12 hours is a standard nursing intervention but may not specifically address the needs of a client with immunosuppression.
B. Inspecting the client's mouth every 8 hours can help in early detection of mouth sores or infections, which are common in immunosuppressed individuals.
C. Providing fresh fruit with meals may not be appropriate for a client with immunosuppression, as fresh fruits can harbor pathogens that pose a risk of infection.
D. Rotating healthcare staff caring for the client helps increases the risk of introducing pathogens to the client. This increases the risk of infection in the immunosuppressed client.
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Related Questions
Correct Answer is C
Explanation
A. Having social support from friends is a protective factor against child abuse.
B. Seeking support from other parents indicates a healthy coping mechanism and reduces the risk of child abuse.
C. This statement suggests unrealistic expectations about the baby's development and behavior, which could lead to frustration and increased risk of child abuse. Unrealistic expectations are a risk factor for abusive behavior towards children.
D. This statement reflects attentiveness and responsiveness to the baby's needs, which reduces the risk of child abuse.
Correct Answer is C
Explanation
A. Both fontanels show molding. Molding is seen immediately after birth due to the passage through the birth canal and should not be present at 8 months.
B. The posterior fontanel is open. The posterior fontanel usually closes by 2 to 3 months of age.
C. For an 8-month-old infant, it is normal for the anterior fontanel to still be open. It typically closes between 12 to 18 months of age.
D. Both fontanels are the same size. The anterior and posterior fontanels are naturally different sizes; the anterior is larger.
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