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 C
Explanation
A. This is not an appropriate action as it can increase pressure on the bladder and worsen the spasms.
B. While warming the irrigation solution can help to prevent discomfort, it is not the most effective way to address the bladder spasms.
C. Belladonna and opium suppositories are commonly used to relieve bladder spasms. They work by relaxing the muscles in the bladder and reducing pain. In a client who has undergone TURBT and is experiencing continuous bladder irrigation, these suppositories can be an effective way to manage discomfort.
D. Meperidine is a narcotic pain reliever that can be used to manage pain after surgery. However, it is not specifically indicated for bladder spasms and may not be the most appropriate medication in this case.
Correct Answer is C
Explanation
A. This value is within the normal range for adult males (14-17.3 g/dL) and borderline for females (11.7- 15.5 g/dL). While the specific context of the patient (e.g., gender) matters, generally, a hemoglobin level of 14 g/dL would not typically cause concern.
B. A platelet count of 150,000/mm³ is at the lower limit of normal (150,000-450,000/mm³). While this may be concerning in certain clinical contexts, it is still within the acceptable range and would not typically raise alarm for a post-op nephrectomy patient unless there are other indications of bleeding or clotting issues.
C. This white blood cell count is elevated (normal range is 4.5-11.1 x 10³/mm³). An elevated WBC count can indicate an infection, inflammation, or a response to surgery, which is particularly concerning post- operatively. This result would warrant further investigation to rule out infection, which is critical for recovery.
D. The neutrophil percentage of 59% is within the normal range (typically around 40-70% for total WBCs). While it is slightly elevated, it is not concerning on its own without additional context, especially since it may be elevated in response to surgery or stress.
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