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 C
Explanation
Choice A rationale
Providing articles from the Internet may not always be reliable and might overwhelm or confuse the client, especially at an emotionally sensitive time.
Choice B rationale
While reassuring the client is important, simply assuring them that the provider will explain later does not empower the client to be actively involved in their care.
Choice C rationale
Encouraging the client to write down questions helps them take an active role in their treatment planning, ensures they remember their concerns, and facilitates a more productive conversation with the provider.
Choice D rationale
Suggesting the client wait for the next appointment can increase anxiety and leave the client feeling unsupported during a critical time when they need information and emotional support.
Correct Answer is D
Explanation
Choice A rationale
Diarrhea is not a typical adverse effect of radiation treatment for breast cancer; gastrointestinal symptoms are more common with abdominal or pelvic radiation.
Choice B rationale
Anorexia, or loss of appetite, can occur but is not as common as fatigue for clients undergoing radiation treatment.
Choice C rationale
Alopecia can occur with chemotherapy, but it is less common with radiation therapy unless the radiation is directed at the scalp.
Choice D rationale
Fatigue is a common and expected adverse effect of radiation therapy due to the body's response to treatment and tissue repair processes.
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