The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?

Two areas of lymph nodes above and below the diaphragm

Two or more areas on the same side of the diaphragm

Localized in the cervical neck area only

Generalized throughout the body within multiple organs

Answer and Explanation

The Correct Answer is D

A. Two areas of lymph nodes above and below the diaphragm: This describes stage III Hodgkin disease, where lymph node involvement occurs both above and below the diaphragm, but not necessarily in multiple organs.

B. Two or more areas on the same side of the diaphragm: This corresponds to stage II Hodgkin disease, which is limited to two or more lymph node regions on the same side of the diaphragm.

C. Localized in the cervical neck area only: Stage I Hodgkin disease typically involves a single lymph node region, often the cervical nodes, without generalized or extensive spread.

D. Generalized throughout the body within multiple organs: In stage IV Hodgkin disease, the cancer has spread beyond the lymph nodes to other organs and tissues, leading to generalized lymphadenopathy and potential organ involvement.

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Correct Answer is B

Explanation

A. Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.

B. Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.

C. Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.

D. Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.

A. The patient should increase intake of fluids. B. The patient should increase intake of fresh fruits. C. The patient should decrease intake of red meat. D. The patient should avoid alcoholic beverages.

Correct Answer is A

Explanation

A. The patient should increase intake of fluids. Increased fluid intake helps flush excess calcium from the kidneys, which is vital for patients with hypercalcemia, a common complication of multiple myeloma.

B. The patient should increase intake of fresh fruits. Fresh fruits can be healthy but do not directly reduce hypercalcemia risk. Fluid intake is more critical in preventing calcium build up.

C. The patient should decrease intake of red meat. While reducing red meat can be beneficial for overall health, it does not directly address hypercalcemia.

D. The patient should avoid alcoholic beverages. Avoiding alcohol is generally beneficial, but it is not specifically related to managing hypercalcemia in multiple myeloma.

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The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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