Which initial assessment finding(s) would the nurse expect in a client diagnosed with acute lymphocytic leukemia (ALL)?
Petechiae and epistaxis
Generalized edema and rash
Alopecia and pallor
Bradycardia and lethargy
The Correct Answer is A
A. Petechiae (small red or purple spots caused by bleeding under the skin) and epistaxis (nosebleeds) result from thrombocytopenia, which is a low platelet count often seen in leukemia. The compromised bone marrow function leads to inadequate production of platelets, resulting in bleeding and bruising.
B. While generalized edema and rash can occur in various conditions, they are not specific to ALL and are not common initial findings. Edema might be seen in certain contexts (e.g., renal involvement or fluid overload), but it is not a hallmark of ALL.
C. Alopecia (hair loss) and pallor (paleness) can occur in clients undergoing chemotherapy for ALL, but they are not typically initial findings at the time of diagnosis. Pallor may result from anemia, which can develop as a consequence of the disease, but it is not the most immediate or characteristic symptom of ALL.
D. Bradycardia (slow heart rate) and lethargy are not typical initial findings of ALL. Lethargy could be present due to anemia or other systemic effects, but bradycardia is not commonly associated with the disease and would require further investigation for other underlying causes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["14"]
Explanation
154 lbs ÷ 2.2 lbs/kg = 70 kg
20 units/kg * 70 kg = 1400 units
1400 units ÷ 25,000 units/250 mL = 14 mL
Therefore, the nurse will administer 14 mL of Heparin.
Correct Answer is C
Explanation
A. This response shows some awareness but does not indicate a sufficient understanding of the risks. Straight razors can pose a significant risk of cuts and bleeding, especially in a patient who has received t- PA, which can increase the likelihood of bleeding.
B. This response suggests a misunderstanding. Using multiple razor blades does not inherently reduce the risk of bleeding and could increase the chance of cuts or nicks. This response does not indicate an appropriate understanding of safety precautions related to t-PA.
C. This response indicates an understanding of safety precautions. Electric razors are safer for clients who are at risk of bleeding because they do not have sharp blades that can easily cause cuts. This choice minimizes the risk of injury while allowing for personal grooming.
D. While disposable razors may seem convenient, they still carry a risk of cuts and bleeding. This response does not reflect a full understanding of the precautions necessary for a client who has received t-PA, as it does not prioritize safety in the same way that using an electric razor does.
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