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 B
Explanation
Choice A rationale
Rapid restoration of serum sodium levels can lead to central pontine myelinolysis, a severe neurological condition. Thus, management should be gradual.
Choice B rationale
SIADH occurs due to excessive release of antidiuretic hormone (ADH) from the posterior pituitary gland, not the anterior, leading to water retention and hyponatremia.
Choice C rationale
SIADH is characterized by concentrated urine due to water retention and overhydration, not diluted urine output and dehydration.
Choice D rationale
Serum sodium levels typically decrease in SIADH due to water retention and dilutional hyponatremia.
Correct Answer is C
Explanation
Choice A rationale
Monitoring for fluid volume excess is not typically a concern for children with Addison's disease, as they are more prone to fluid volume deficit due to adrenal insufficiency.
Choice B rationale
Placing the child on a low-sodium diet is inappropriate for Addison's disease, as these patients often need increased sodium intake due to their impaired ability to retain sodium.
Choice C rationale
Teaching the parents about cortisol replacement therapy is crucial in managing Addison's disease, as the condition involves adrenal insufficiency requiring hormone replacement to manage symptoms and prevent adrenal crisis.
Choice D rationale
Discussing the manifestations of hyperglycemia is not relevant, as Addison's disease is more commonly associated with hypoglycemia due to reduced cortisol production.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.