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 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
Examining the client for hepatomegaly can be part of a broader assessment but does not directly address the fatigue related to chemotherapy, particularly cisplatin, which is known to cause bone marrow suppression.
Choice B rationale
Assessing for a hypersensitivity reaction is important during chemotherapy, but it does not specifically address the issue of fatigue, which is often related to blood cell counts.
Choice C rationale
Checking the results of the client's most recent CBC (complete blood count) is crucial because cisplatin can cause anemia, leukopenia, and thrombocytopenia, all of which can lead to significant fatigue.
Choice D rationale
Evaluating for hypercalcemia is not typically associated with cisplatin treatment; it is more relevant in malignancies associated with bone metastasis or overproduction of parathyroid hormone-related protein.
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