Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?
Urine sample has Bence-Jones protein.
Patient is complaining of severe back pain.
Serum calcium level is 15 mg/dL.
Patient reports no stool for 5 days.
The Correct Answer is C
A. Presence of Bence-Jones protein in the urine is indicative of multiple myeloma, but hypercalcemia is a more urgent issue to address.
B. Severe back pain is common in multiple myeloma due to bone involvement, but it is not as immediately life-threatening as hypercalcemia.
C. Elevated serum calcium levels (hypercalcemia) are a common complication of multiple myeloma and can lead to various complications, including kidney damage, altered mental status, and cardiac arrhythmias. Therefore, it is crucial to report significantly elevated serum calcium levels promptly to the health care provider for appropriate management.
D. Patient reports no stool for 5 days may indicate constipation, which is important to address but is not as urgent as hypercalcemia in the context of multiple myeloma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inadequate production of platelets results in an increased risk of bleeding, making the client vulnerable to injury. Therefore, the priority nursing diagnosis is "Risk for Injury related to increased bleeding tendency."
B. Decreased antibody production is not directly related to inadequate platelet production.
C. While decreased platelet production may contribute to hypovolemia in some cases, the primary concern is the risk of bleeding rather than decreased cardiac output.
D. Impaired gas exchange is not directly related to inadequate platelet production.
Correct Answer is ["A","B","D","E"]
Explanation
A. Feeling for changes in the underarm area is important as breast tissue extends into this region and lumps can form there.
B. Since menopausal women do not have periods, they can perform BSE at any consistent time each month to help remember to do it regularly.
C. Pressing the breasts too firmly could cause discomfort and is not necessary for detecting lumps.
D. Performing BSE in the shower is effective because the soapy water allows the fingers to move smoothly over the skin.
E. Using fingertips is the proper technique for checking breasts, as it allows for more sensitivity in detecting changes in the breast tissue.
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