A nurse is caring for a 33-year-old male client in the oncology unit who was recently diagnosed with multiple myeloma. The client is currently receiving an induction chemotherapy protocol consisting of vincristine, dexamethasone, L-asparaginase, and anthracycline. The nurse must evaluate the client's condition based on the exhibits provided to determine appropriate actions and parameters to monitor.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for correct condition: Mucositis is a common side effect of chemotherapy that causes inflammation and soreness in the mouth. The client reports mouth soreness and dry mucous membranes, consistent with mucositis. The presence of mild erythema on the oral mucosa also supports this diagnosis. Chemotherapy drugs such as vincristine and anthracycline are known to cause mucositis. Addressing mucositis early is crucial for maintaining the client’s nutrition and hydration.
Rationale for actions: Providing a soft sponge toothbrush helps maintain oral hygiene without causing further irritation. Maintaining the client’s diet ensures adequate nutrition, which is essential for healing mucositis. Pad the siderails of the bed is unnecessary in this scenario, as there's no indication of seizure risk. Requesting an antiemetic is irrelevant since the client has no significant nausea or vomiting.
Rationale for parameters: Monitoring weight loss helps assess the client’s nutritional status and the effectiveness of dietary interventions. Tracking intake and output ensures the client is adequately hydrated and that oral intake is sufficient. Edema monitoring is unnecessary, as there's no sign of fluid retention. Steatorrhea is not relevant in this context, as there's no indication of fat malabsorption.
Rationale for incorrect conditions: Diarrhea is not indicated as the client’s primary complaint is mouth soreness, not gastrointestinal upset. Angioedema is characterized by swelling and is not observed in the client. Seizures are not relevant here, as the client shows no neurological signs suggestive of seizure activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Prednisone does not increase bone density; in fact, long-term use can cause bone demineralization and osteoporosis.
Choice B rationale
Prednisone can actually increase the risk of infection by suppressing the immune system.
Choice C rationale
Prednisone does not improve peripheral blood flow; it mainly works by reducing inflammation and suppressing immune responses.
Choice D rationale
Prednisone helps to reduce creatinine levels by decreasing inflammation and immune responses, which is beneficial in treating acute kidney rejection.
Correct Answer is B
Explanation
Choice A rationale
An RBC count of 5 million/mm³ is within the normal range for adult females, so this finding would not be concerning in the context of chemotherapy.
Choice B rationale
A WBC count of 2300/mm³ is significantly lower than the normal range (typically 4500 to 11000/mm³) and indicates neutropenia, which is a critical side effect of chemotherapy that needs to be reported immediately.
Choice C rationale
Hemoglobin level of 12 g/dL is within the normal range for adult females, so this would not be concerning in the context of chemotherapy.
Choice D rationale
A platelet count of 155,000/mm³ is within the normal range (150,000 to 450,000/mm³). Although on the lower end, it is not typically alarming enough to report immediately in the context of chemotherapy.
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