A client with acute lymphocytic leukemia received induction chemotherapy. The client's absolute neutrophil count is zero, and the client is experiencing fatigue and mild nausea. Which nursing action is the highest priority?
Assess for sources of bleeding and provide pressure on wounds
Limit contact with infected visitors and place in positive pressure isolation
Administer antiemetics and assess nutrition and hydration status
Monitor energy levels and begin energy-conserving techniques
The Correct Answer is B
A. Assessing for sources of bleeding is important in clients with neutropenia, but the highest priority is preventing infection, as the client’s absolute neutrophil count is zero, indicating an extremely high risk for infection.
B. Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
C. Administering antiemetics and assessing nutrition and hydration are important for managing symptoms, but they do not address the immediate risk of infection associated with severe neutropenia.
D. Monitoring energy levels and implementing energy-conserving techniques are important for overall care but do not address the urgent need to protect the client from infections due to their neutropenic status.
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Related Questions
Correct Answer is D
Explanation
D. Bradykinesia, or slowness of movement, is a hallmark symptom of Parkinson's disease. It is characterized by a gradual reduction in the speed of voluntary movements and is one of the primary motor symptoms associated with the disease.
A. Chorea, characterized by involuntary, irregular movements, is more commonly associated with Huntington's disease rather than Parkinson's disease.
B. Pruritus (itching) is not a characteristic symptom of Parkinson's disease.
C. Xerostomia (dry mouth) is not a primary symptom of Parkinson's disease, though it may occur as a secondary effect.
Correct Answer is B
Explanation
A. Distributive shock is associated with decreased MAP, not increased.
B. Decreased venous return occurs in distributive shock due to the pooling of blood in the periphery, leading to reduced preload and decreased cardiac output.
C. Distributive shock typically results in increased heart rate as the body attempts to compensate for decreased blood pressure and venous return.
D. Cardiac output is generally decreased in distributive shock due to reduced venous return and impaired blood flow.
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