A nurse is planning care for a client who is receiving chemotherapy and has neutropenia.
Which of the following interventions should the nurse include in the plan?
Avoid including raw fruits in the client's diet.
Restrict visits from young children to 2 hr per day.
Measure the client's temperature once per shift.
Use disposable gloves from a box outside the client's room.
The Correct Answer is A
- A. The nurse should discourage raw fruits due to risk of infection.
- B. There is no standard recommendation against exposure to young children.
- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Borderline.
- A. Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity and recurrent suicidal behavior. The client's history of seeking counseling for relationship problems and selfinflicted lacerations are consistent with this disorder. Therefore, this choice is correct.
- B. Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, as well as a lack of remorse for one's actions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
- C. Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others, as well as a tendency to interpret others' motives as malevolent. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
- D. Histrionic personality disorder is characterized by excessive emotionality and attentionseeking behavior, as well as a tendency to dramatize situations and exaggerate emotions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
Correct Answer is D
Explanation
- A. Instructing the client about the importance of regular medical appointments is important, but not the priority. The nurse should first ensure that the client knows how to manage their blood glucose levels and administer insulin at home.
- B. Encouraging the client to participate in daily exercise is beneficial, but not the priority. The nurse should first ensure that the client knows how to monitor their blood glucose levels and adjust their insulin dose accordingly.
- C. Explaining proper foot care techniques to the client is essential, but not the priority. The nurse should first ensure that the client knows how to prevent and treat hypoglycemia and hyperglycemia, which can have serious complications.
- D. Ensuring that the client understands the medication regimen is the priority. The nurse should teach the client about the types, actions, doses, and administration times of insulin, as well as how to store and dispose of it safely.
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