A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?

Reference Range:

Platelet count [150,000 to 400,000/mm3 (150 to 400 x 109/L)]

Monitor for signs of activity intolerance.

Require visitors to wear respiratory masks.

Assess urine and stool for occult blood.

Obtain client's temperature every 4 hours.

Answer and Explanation

The Correct Answer is C

A. Monitoring for activity intolerance is important in clients with anemia, which is common in leukemia and chemotherapy due to decreased red blood cells. However, a platelet count of 25,000/mm³ indicates severe thrombocytopenia, placing the client at high risk for bleeding rather than fatigue-related complications. Therefore, while this assessment may be relevant, it is not the priority intervention for this platelet level.

B. Requiring visitors to wear respiratory masks is an infection control measure appropriate for clients with neutropenia (low white blood cell count). Although myelosuppressive chemotherapy can also reduce white blood cells, the question specifically highlights a critically low platelet count. Thus, bleeding—not infection—is the immediate concern, making this option less relevant to the current priority.

C. This is the most important intervention. A platelet count of 25,000/mm³ significantly increases the risk of spontaneous bleeding, including internal bleeding that may not be immediately visible. Assessing urine and stool for occult blood allows for early detection of hidden (internal) bleeding in the gastrointestinal or urinary tract. Early identification enables prompt intervention, such as platelet transfusions or activity restrictions, to prevent life-threatening hemorrhage. Monitoring for bleeding is a priority in severe thrombocytopenia.

D. Monitoring temperature every 4 hours is appropriate for detecting infection, especially in immunocompromised clients. However, this intervention is more directly related to neutropenia rather than thrombocytopenia. While still important in the overall care of a client receiving chemotherapy, it is not the priority given the immediate risk of bleeding associated with the critically low platelet count.

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Correct Answer is A

Explanation

A. This is the most effective and evidence-based approach. Starting with less sensitive questions helps build rapport, establish trust, and make the client feel safe before addressing more personal or potentially traumatic topics such as domestic violence. Gradually increasing the sensitivity of questions allows the client to respond more comfortably and reduces the risk of retraumatization.

B. Asking vague or non-specific questions may confuse the client and result in incomplete or inaccurate information. Clear, specific, and open-ended questions are essential for accurate assessment.

C. Sharing personal values is inappropriate in a professional healthcare setting. It can shift focus away from the client and may influence or bias the client’s responses. The nurse’s role is to remain objective and supportive.

D. Asking the most difficult questions first can intimidate or distress the client, potentially causing them to withhold information or disengage from the interview. A gradual, sensitive approach is recommended for topics like suspected abuse.

A. "The leg weakness is caused by reduced blood flow to the peripheral nerves." B. "The leg weakness is caused by psychological stress, temporarily affecting nerve function." C. "The leg weakness is caused by immune damage to the myelin sheath of the nerves." D. "The leg weakness is caused by prolonged immobility and muscle disuse."

Correct Answer is C

Explanation

A. Reduced blood flow to peripheral nerves can cause ischemic neuropathy, but this is not the underlying mechanism in Guillain-Barré syndrome (GBS). Blood flow is typically adequate, and ischemia is not the primary cause of weakness.

B. Psychological stress may temporarily affect perception of strength or coordination, but GBS is an autoimmune neurological disorder with a physiological cause, not a psychosomatic one.

C. This is the correct explanation. Guillain-Barré syndrome is an acute autoimmune disorder in which the body’s immune system attacks the myelin sheath of peripheral nerves. Damage to myelin slows or blocks nerve signal transmission, leading to progressive, symmetrical weakness that typically begins in the legs and ascends upward. Explaining this mechanism helps the client understand the physiological basis of their symptoms.

D. Prolonged immobility and muscle disuse can lead to weakness over time (atrophy), but this is a secondary effect. The primary cause of acute leg weakness in GBS is demyelination of peripheral nerves, not disuse.

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A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet count [150,000 to 400,000/mm3 (150 to 400 x 109/L)]

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Explanation

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A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?

Reference Range:

Platelet count [150,000 to 400,000/mm3 (150 to 400 x 109/L)]