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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. This is a significant finding that warrants immediate notification. Changes in mental status in elderly patients can indicate a variety of issues, including infection (such as a urinary tract infection), dehydration, or other acute illnesses. Given that elderly patients are at higher risk for delirium and other cognitive changes, this finding should be taken seriously.
B. These vital signs are largely within normal limits for an elderly patient. While the blood pressure is on the higher side, the heart rate and respiratory rate are within acceptable ranges. Therefore, this does not warrant immediate notification unless other symptoms are present.
C. This statement is reassuring and suggests that the client is not experiencing complications related to the indwelling catheter, such as infection or obstruction. It does not indicate any need for immediate notification of the provider.
D. Cloudy urine with sediment can be indicative of a urinary tract infection (UTI) or other complications related to the indwelling catheter. While this finding is concerning and may require further evaluation, it is not as urgent as a change in mental status. It should still be reported to the healthcare provider but may not necessitate immediate action.

A. Avoid sexual activity for twelve hours B. Teach to self-catheterize every 4 hours C. Urinate in a sitting position post infusion D. Increase fluid intake for 8 hours prior to infusion

Correct Answer is C

Explanation

A. After intravesical therapy, there may be recommendations to avoid sexual activity for a certain period (often 24 hours) to prevent exposure to the medication by a partner. However, the specifics can vary based on the medication used. Twelve hours might not be sufficient depending on the protocol.
B. Self-catheterization is not routinely required unless there is a specific reason (e.g., urinary retention or difficulty voiding). This statement is not relevant to the therapy itself.
C. Urinating in a sitting position can help ensure more complete emptying of the bladder and can be safer, particularly for women. It also may minimize contact with any residual medication in the bladder, which can be a consideration post-infusion.
D. Patients are usually advised to avoid excessive fluid intake immediately before the infusion to prevent bladder distention during the treatment.

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Which initial assessment finding(s) would the nurse expect in a client diagnosed with acute lymphocytic leukemia (ALL)?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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