The nurse is assessing a patient who has received the first dose of chemotherapy for leukemia.
Which patient's clinical findings indicate to the nurse that the patient has developed tumor lysis syndrome (TLS)?

Facial swelling and jugular vein distension (JVD).

Muscle weakness, confusion, polyuria, and polydipsia.

Flank pain, elevated uric acid, and cardiac monitor reveals an abnormal rhythm.

Elevated liver function tests, jaundice, and blistering skin rash.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale

Facial swelling and jugular vein distension (JVD) are indicative of superior vena cava syndrome (SVCS), not tumor lysis syndrome (TLS). SVCS occurs when the superior vena cava, which carries blood from the head, neck, upper chest, and arms to the heart, is obstructed. This can lead to facial swelling, cyanosis, and distended neck veins due to increased venous pressure.

Choice B rationale

Muscle weakness, confusion, polyuria, and polydipsia are symptoms of hypercalcemia. Hypercalcemia is characterized by elevated levels of calcium in the blood, which can cause neuromuscular and cognitive symptoms, excessive urination, and increased thirst.

Choice C rationale

Tumor lysis syndrome (TLS) is characterized by rapid destruction of tumor cells, leading to elevated levels of uric acid, potassium, and phosphate. Symptoms include flank pain due to uric acid crystallization in the kidneys, and abnormal heart rhythms due to hyperkalemia.

Choice D rationale

Elevated liver function tests, jaundice, and blistering skin rash are symptoms of liver toxicity or hepatic dysfunction, possibly due to drug-induced liver injury. These symptoms are not related to tumor lysis syndrome (TLS).

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

An increase in systolic blood pressure by 25 mmHg indicates a positive response to therapy for Addisonian crisis. Addisonian crisis involves severe hypotension due to low levels of cortisol and aldosterone, which regulate blood pressure. Cortisol replacement therapy helps to increase blood pressure by enhancing the responsiveness of blood vessels to catecholamines and promoting sodium and water retention. This improvement is critical for stabilizing the patient and restoring hemodynamic balance.

Choice B rationale

An increase in serum potassium level from 3.5 to 5.6 mEq/dL suggests hyperkalemia, which is a sign of worsening condition, not improvement. Addisonian crisis is characterized by hyperkalemia due to aldosterone deficiency, which impairs potassium excretion. Effective treatment would normalize potassium levels rather than increase them.

Choice C rationale

Complaints of headache and signs of restlessness may indicate adverse effects or complications, rather than therapeutic efficacy. These symptoms could result from inadequate or excessive dosing of corticosteroids or other underlying issues. Monitoring patient response and adjusting treatment is essential.

Choice D rationale

Normal temperature with pallor to the skin does not indicate effective therapy for Addisonian crisis. Pallor may reflect ongoing hypoperfusion or anemia. The absence of fever is not a definitive marker of therapeutic success. Key indicators include hemodynamic stability and normalized electrolytes.

A. Pain 6/10 from mucositis and oral tissue injury. B. Weakness and fatigue with activity. C. Blood pressure 90/64 mmHg, pulse 102 beats per minute, oral temperature 38.5 degrees C. D. Scattered ecchymosis and petechiae noted on arms.

Correct Answer is C

Explanation

Choice A rationale

Pain from mucositis and oral tissue injury is a significant concern for patients undergoing chemotherapy. However, it is not typically life-threatening and can be managed with appropriate pain relief measures and oral care.

Choice B rationale

Weakness and fatigue with activity are common side effects of chemotherapy and the disease process itself. While these symptoms impact the patient's quality of life, they do not usually require urgent intervention.

Choice C rationale

Blood pressure of 90/64 mmHg, pulse of 102 beats per minute, and oral temperature of 38.5 degrees Celsius suggest possible sepsis or severe infection. These vital signs indicate an urgent need for intervention to prevent further deterioration and potentially life-threatening complications.

Choice D rationale

Scattered ecchymosis and petechiae are signs of thrombocytopenia (low platelet count), which is a common complication of leukemia and its treatment. While important to monitor and manage, these findings are not typically as urgent as signs of sepsis or severe infection.

View Question and Answer

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

The nurse is assessing a patient who has received the first dose of chemotherapy for leukemia.Which patient's clinical findings indicate to the nurse that the patient has developed tumor lysis syndrome (TLS)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who was treated for Addisonian crisis.What clinical change indicates to the nurse that the prescribed therapy was effective?

Correct Answer is A

Explanation

The nurse on the oncology unit is caring for a patient receiving chemotherapy for treatment of leukemia.Which patient finding is the nurse's priority for implementing interventions?

Correct Answer is C

Explanation

The nurse manager is orienting a new nurse to the oncology unit.What will the nurse manager teach about best practices for safe handling and administration of chemotherapy?

The nurse is caring for a patient with Addison's disease in the emergency department.The patient states that they were out in the sun gardening all day and is now lethargic, forgetful, and has a temperature of 101.5°F. What intervention will the nurse prioritize when caring for this patient?

The nurse is providing discharge teaching to a patient diagnosed with Cushing's syndrome.What statement made by the patient will demonstrate their understanding of the discharge instructions?

The nurse is evaluating a patient with hyperthyroidism who is taking propylthiouracil (PTU) 100 mg/day for maintenance therapy.Which statement from the patient indicates the medication therapy is effective?

The nurse is assessing a patient with metastatic prostate cancer who was admitted with sudden onset of back pain, lower extremity weakness, difficulty walking, and paresthesia in their toes.What intervention will the nurse implement for this patient?

The nurse is assessing a patient with prostate cancer who is receiving chemotherapy.What findings will the nurse identify as potential toxicities of this treatment? Select All That Apply.

The nurse is caring for a patient with hypothyroidism who is prescribed levothyroxine.Which assessment data indicates to the nurse that the medication has been effective?

The nurse is assessing a patient who has received the first dose of chemotherapy for leukemia.
Which patient's clinical findings indicate to the nurse that the patient has developed tumor lysis syndrome (TLS)?