A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?
Chest pain and dyspnea.
Seizures.
Hematuria.
Swelling of the extremities.
The Correct Answer is B
Choice A rationale
Chest pain and dyspnea are concerning symptoms but are not the most immediate manifestations to report in a client undergoing radiation therapy for brain cancer. These symptoms could be related to other conditions and require further evaluation.
Choice B rationale
Seizures are the most immediate manifestation to report because they indicate increased intracranial pressure or other neurological complications related to brain cancer and radiation therapy. Seizures require prompt medical intervention to prevent further complications.
Choice C rationale
Hematuria is a concerning symptom but is not the most immediate manifestation to report in this context. It could be related to other conditions and requires further evaluation.
Choice D rationale
Swelling of the extremities is a concerning symptom but is not the most immediate manifestation to report in this context. It could be related to other conditions and requires further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A WBC count of 2300/mm³ is significantly lower than the normal range (4500-11000/mm³) and indicates leukopenia, which increases the risk of infection. This finding should be reported to the provider.
Choice B rationale
A platelet count of 155,000/mm³ is within the lower end of the normal range (150,000- 450,000/mm³) and does not require immediate reporting.
Choice C rationale
An RBC count of 5 million/mm³ is within the normal range for females (4.2-5.4 million/mm³) and does not require immediate reporting.
Choice D rationale
A hemoglobin level of 12 g/dL is within the normal range for females (12-16 g/dL) and does not require immediate reporting.
Correct Answer is D
Explanation
Choice A rationale
Instructing to slowly exhale with pursed lips is a breathing technique but not the first action to take before the procedure.
Choice B rationale
Assessing pulse and respirations is important but not the first action to take before the procedure.
Choice C rationale
Assessing characteristics of her sputum is important but not the first action to take before the procedure.
Choice D rationale
Auscultating lung fields is the first action to take to assess the client’s current respiratory status and determine the effectiveness of the upcoming procedure.
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