The client has developed graft versus host disease (GVHD) during treatment for acute lymphoblastic leukemia (ALL). The client has a generalized pruritic rash on the trunk and the extremities. What nursing measures should the nurse use to address this problem?

Apply bacitracin liberally to the affected areas

Request a medical prescription for diphenhydramine or hydroxyzine

Instruct client to shower with cool water and use a mild soap

Clip fingernails and encourage the use of prescribed lotions

Answer and Explanation

Correct Answer : B,C,D

A.   Bacitracin is an antibiotic ointment typically used to prevent or treat bacterial infections in minor cuts and scrapes. It is not appropriate for treating a pruritic rash associated with GVHD. The rash may not be due to an infection but rather an immune response, so using bacitracin would not address the underlying issue.
B.   Diphenhydramine (Benadryl) and hydroxyzine are antihistamines that can help alleviate itching and provide relief from pruritus. Requesting a prescription for one of these medications is an appropriate response to manage the symptoms of GVHD.
C.   Showering with cool water can soothe irritated skin and reduce itching. Using mild soap helps to avoid further irritation or dryness that harsher soaps can cause. This intervention supports skin care and helps manage pruritus effectively.
D.   Clipping fingernails can help prevent skin damage from scratching, which could lead to secondary infections. Encouraging the use of prescribed lotions can help keep the skin moisturized and alleviate dryness, further addressing the pruritus associated with GVHD.

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Correct Answer is C

Explanation

A. An ischemic stroke occurs when a blood vessel supplying blood to the brain is obstructed. Common symptoms include sudden numbness or weakness in the face, arm, or leg, confusion, difficulty speaking, and visual disturbances. However, "thunderclap" headache and neck stiffness are not typical symptoms of an ischemic stroke.
B. A TIA, often referred to as a "mini-stroke," produces similar symptoms to a stroke but lasts for a short duration (typically less than 24 hours) and does not cause permanent damage. Symptoms can include weakness, speech difficulties, and visual changes, but again, "thunderclap" headache and neck stiffness are not characteristic of a TIA.
C. A subarachnoid hemorrhage occurs when there is bleeding into the space between the brain and the tissues covering it, often due to a ruptured aneurysm. A "thunderclap" headache, described as an extremely sudden and severe headache, is a hallmark of this condition.
D. A cardioembolic stroke is a type of ischemic stroke that occurs when a blood clot forms in the heart and travels to the brain. Symptoms are similar to those of an ischemic stroke and do not typically include a "thunderclap" headache or neck stiffness.

A. Flank mass and hematuria B. Dark tarry stool and mental status change C. Shortness of breath and chest pain D. Urinary frequency and hypotension

Correct Answer is A

Explanation

A. Renal cancer can often present with a palpable flank mass due to tumor growth. Hematuria (blood in the urine) is also a common finding in patients with kidney tumors and can result from bleeding within the renal system. Flank pain, especially in the context of renal cancer, often accompanies these findings.
B. Dark, tarry stools (melena) suggest gastrointestinal bleeding, which is not directly associated with renal cancer. Mental status changes could indicate various issues, such as metabolic imbalances or anemia, but they are not specific findings for renal cancer.
C. While patients with advanced cancer may experience shortness of breath due to metastasis to the lungs or other complications, chest pain is not a direct finding associated with renal cancer. These symptoms could indicate other issues, such as cardiac or pulmonary problems.
D. While urinary frequency can occur due to various urinary tract issues, it is not a classic symptom of renal cancer. Hypotension is also not a typical finding associated with renal cancer unless there is significant blood loss or other complications.

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The client has developed graft versus host disease (GVHD) during treatment for acute lymphoblastic leukemia (ALL). The client has a generalized pruritic rash on the trunk and the extremities. What nursing measures should the nurse use to address this problem?

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Naxlex Comprehensive Predictor Exams

The client is admitted with complaints of photosensitivity, neck stiffness, and a "thunderclap" headache. The nurse recognizes that these clinical manifestations would present with which type of stroke?

Correct Answer is C

Explanation

A nurse is assessing a client diagnosed with renal cancer. The client is complaining of flank pain. Which additional assessment finding should the nurse expect?

Correct Answer is A

Explanation

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The client has developed graft versus host disease (GVHD) during treatment for acute lymphoblastic leukemia (ALL). The client has a generalized pruritic rash on the trunk and the extremities. What nursing measures should the nurse use to address this problem?