A client diagnosed with acute myelogenous leukemia (AML) develops a platelet count of 10,000 mm3 during chemotherapy treatment. What is an appropriate nursing intervention for this client, based on this finding?

Table 34.1 Review of Normal Ranges for Complete Blood Cell Counts (Adult)

Blood Cell

Normal Ranges

Red blood cells (mature, circulating)

Male: 451-6.01 million/mm3

Female: 4.01-5.51 million/mm3

Hemoglobin

Adult (15-64 yr)

Male 14-17.3 g/dL

Female 11.7-155 g/dL

Hematocrit

42%-52% in males

36% -48% in females

Reticulocytes

0.5% -2.5% of total RBC count

White blood cells (total)

4.5-11.1 10/mm3

Neutrophils

59%

Bands 3% Segs-56%

Eosinophils

2.7%

Basophils

0.5%

Lymphocytes

34%

Monocytes

4%

Platelets

150,000-450,000/mm3

Obtain a prescription for stool occult blood testing

Encourage intake of oral fluids to 3000 mL/day

Assess the temperature every four hours

Provide oral hygiene every two hours

Answer and Explanation

The Correct Answer is C

A.   This intervention can be appropriate since a very low platelet count increases the risk of bleeding, including gastrointestinal bleeding. However, this action alone does not directly address the immediate risks associated with the low platelet count.
B.   While hydration is important for overall health, this intervention does not specifically address the risks associated with a low platelet count. Additionally, excessive fluid intake may not be appropriate for all patients, especially if there are underlying kidney issues or fluid restrictions.
C.   Clients with AML and low platelet counts are at increased risk for infections and may develop febrile neutropenia. Monitoring temperature every four hours can help detect early signs of infection, allowing for timely intervention.
D.   While maintaining oral hygiene is important, especially in patients undergoing chemotherapy, this intervention may not be the most critical action based on the acute concern of a very low platelet count. However, it is important to note that patients with low platelet counts may also experience bleeding from the gums, making gentle oral care essential.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Using adaptive equipment suggests they are finding ways to maintain independence and complete activities of daily living (ADLs) despite any physical or cognitive limitations. This is a positive sign of adaptation.
B. Difficulty using modified feeding utensils suggests that the client is struggling to adapt to the changes caused by the stroke. If they cannot use these utensils effectively, it indicates a challenge in managing their eating independently, which is not a sign of successful adaptation.
C. While emotional responses like depression and irritability are common after a stroke, experiencing these feelings frequently can indicate difficulty in coping with the changes. This does not reflect successful adaptation; rather, it suggests that the client may be struggling emotionally and psychologically with their new circumstances.
D. While frustration can be a normal response to challenges after a stroke, particularly in the context of regaining independence, getting angry at family members may indicate difficulty in coping with the changes or an inability to manage frustration.

A. Discuss the precipitating factors that caused the symptoms B. Schedule a STAT computed tomography (CT) scan of the head C. Prepare to administer recombinant tissue plasminogen activator (t-PA) D. Notify the Speech Pathologist for an emergency consult

Correct Answer is B

Explanation

A.While it's important to gather information about the client's symptoms, the priority in this situation is to determine the underlying cause of the neurological symptoms. A CT scan can quickly identify if there's been a stroke or other brain injury.
B.This is the most appropriate and urgent intervention. A CT scan can rapidly identify if the client has had a stroke, which is a time-sensitive medical emergency. Early diagnosis and treatment are crucial for minimizing brain damage and improving outcomes.
C.t-PA is a medication used to dissolve blood clots in the brain, but it is only effective if given within a specific time window after the onset of stroke symptoms. Without a confirmed diagnosis of stroke from a CT scan, administering t-PA could be harmful.
D.While a speech pathologist may be involved in the client's care later on, the priority is to determine the underlying cause of the neurological symptoms and initiate appropriate treatment. A CT scan is essential for this purpose.

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Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male: 451-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-155 g/dL
Hematocrit	42%-52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 10/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The rehabilitation nurse determines that the client who has had a hemorrhagic stroke is successfully adapting to functional changes if they:

Correct Answer is A

Explanation

A 78-year-old client is admitted to the Emergency Department (ED) with numbness and weakness of the right arm and slurred speech. Which nursing intervention is a priority?

Correct Answer is B

Explanation

The nurse is performing a health screening of a 37-year-old female client. Which factor(s) would alert the nurse that this client is at greatest risk for developing a stroke?

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?

The client is admitted with complaints of photosensitivity, neck stiffness, and a "thunderclap" headache. The nurse recognizes that these clinical manifestations would present with which type of stroke?

A nurse is caring for a 58-year-old client who is diagnosed with uterine cancer. Which of the following manifestations is likely to be reported by this client?

A client's Pap test reveals cervical cells with dysplasia changes. The nurse understands that information obtained during the client's health history and identified as a major risk factor for cervical cancer is:

The nurse is teaching a client about early detection for penile cancer. The nurse knows the teaching is effective when the client states, "I will: