A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client would the nurse assess first?
Client with a swollen and painful left great toe
Client with a blood pressure of 180/98 mm Hg
Client who reports calf tenderness and swelling
Client who reports shortness of breath
The Correct Answer is C
A. This may indicate gout, which is painful but not immediately life-threatening. While important to assess, it is not the highest priority in polycythemia vera.
B. This indicates severe hypertension, which requires monitoring and intervention, but unless symptoms such as chest pain, neurologic changes, or shortness of breath are present, it is less immediately urgent than signs of a potential thrombotic event.
C. This client may have a deep vein thrombosis (DVT), a serious complication of polycythemia vera due to increased blood viscosity and platelet aggregation. DVT carries a risk for pulmonary embolism, making this the highest priority for assessment and intervention.
D. Shortness of breath is concerning and can indicate hypoxia or pulmonary complications, but in the context of polycythemia vera, a suspected DVT that could embolize is more urgent to assess first.
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Related Questions
Correct Answer is C
Explanation
A. This may indicate gout, which is painful but not immediately life-threatening. While important to assess, it is not the highest priority in polycythemia vera.
B. This indicates severe hypertension, which requires monitoring and intervention, but unless symptoms such as chest pain, neurologic changes, or shortness of breath are present, it is less immediately urgent than signs of a potential thrombotic event.
C. This client may have a deep vein thrombosis (DVT), a serious complication of polycythemia vera due to increased blood viscosity and platelet aggregation. DVT carries a risk for pulmonary embolism, making this the highest priority for assessment and intervention.
D. Shortness of breath is concerning and can indicate hypoxia or pulmonary complications, but in the context of polycythemia vera, a suspected DVT that could embolize is more urgent to assess first.
Correct Answer is A
Explanation
A. Severe chest pain in a child with sickle cell anemia may indicate acute chest syndrome, which is a life-threatening complication characterized by pulmonary infarction, infection, or vaso-occlusion. This can rapidly lead to hypoxia, respiratory distress, and organ damage, so the child requires immediate assessment and intervention, making it the highest priority.
B. This value is slightly diluted but not immediately dangerous. The child is at risk for dehydration, but there is no acute crisis, so it is lower priority than severe chest pain.
C. Fever is expected in roseola and usually self-limiting. The child may be uncomfortable but is not at immediate risk for life-threatening complications.
D. This PCO2 is within normal limits (35–45 mm Hg). While asthma can deteriorate quickly, this reading does not indicate respiratory failure, making it a lower priority.
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