A nurse is caring for a 63-year-old female client in the emergency department (ED) with a history of colorectal cancer. The client is receiving chemotherapy and radiation. She presents with complaints of fatigue, unexplained bruising, and recurring headaches. The nurse must evaluate the situation based on the exhibits provided to determine the client’s risk factors and findings.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Choice A rationale:
The client's low platelet count (90 x 10⁹/L) is a significant risk factor for developing Disseminated Intravascular Coagulation (DIC), a condition characterized by abnormal blood clotting and bleeding. The client's history of cancer and symptoms such as unexplained bruising and fatigue further support this risk.
Choice B rationale:
Hyperkalemia is characterized by high potassium levels, but the client's potassium level is within the normal range (4.1 mmol/L), so this is not a risk factor.
Choice C rationale:
Hyponatremia is a condition of low sodium levels in the blood. The client's sodium level is normal (137 mmol/L), so this is not a risk factor.
Choice D rationale:
Pneumonia is a lung infection, and the client's oxygen saturation is normal (98% on room air), indicating no immediate risk of pneumonia.
Choice E rationale:
Acute nephritic syndrome is a kidney disorder that can cause elevated blood urea nitrogen (BUN) and creatinine levels. The client's BUN is slightly elevated (22 mg/dL), but her creatinine level is normal (1.0 mg/dL), making this less likely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Systemic lupus erythematosus (SLE) does not originate in the peripheral vascular system. This system involves the blood vessels outside of the heart and brain, and while SLE can affect these vessels, it is not the primary origin of the disease.
Choice B rationale
SLE does not originate in muscle tissue. Muscle involvement in SLE typically results from inflammation caused by the autoimmune response, but muscle tissue is not the source of the disease.
Choice C rationale
Connective tissue is where SLE originates. SLE is an autoimmune disease that primarily targets connective tissue, causing inflammation and damage to various organs and systems throughout the body.
Choice D rationale
The lymphatic system is not the origin of SLE. While the immune system plays a key role in SLE, the disease itself originates in the connective tissue, not the lymphatic system.
Correct Answer is A
Explanation
Choice A rationale
Muscle wasting and osteoporosis are common findings in Cushing's syndrome due to prolonged exposure to high levels of cortisol, which leads to the breakdown of muscle tissue and decreases in bone density.
Choice B rationale
Diaphoresis is not a typical feature of Cushing's syndrome. While excessive sweating can occur in various conditions, it is not a hallmark of Cushing's syndrome, which primarily affects muscle, bone, and fat distribution.
Choice C rationale
Hypotension is not characteristic of Cushing's syndrome. Instead, hypertension is more common due to cortisol's effects on increasing blood pressure through sodium and water retention.
Choice D rationale
Weight loss is not a typical finding in Cushing's syndrome. Individuals with Cushing's syndrome often experience weight gain, particularly around the abdomen, face, and neck, due to cortisol's effects on fat distribution.
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