A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client?
Baked chicken
Bagels
A factory-sealed box of chocolates
Fresh fruit basket
The Correct Answer is D
A. Baked chicken: Baked chicken, if cooked thoroughly, is generally safe for a client with neutropenia (low WBC count) as it does not pose a high risk for infection.
B. Bagels: Bagels, if they are from a safe, uncontaminated source, are generally considered safe for neutropenic clients.
C. A factory-sealed box of chocolates: Factory-sealed chocolates are usually safe as they are unlikely to be contaminated.
D. Fresh fruit basket: Fresh fruits can carry bacteria, especially on the skin or peel, and pose a risk of infection for a client with neutropenia. Therefore, this is the item that should be prohibited.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Disturbed body image related to depression: While body image disturbances can occur with depression, it is not the primary concern following a suicide attempt.
B. Imbalanced nutrition: Less than body requirements related to depression: While nutritional imbalances may be present in clients with depression, the most pressing concern after a suicide attempt is safety.
C. Hygiene self-care deficit related to depression: A self-care deficit is often present in depression but is not the most urgent diagnosis after a suicide attempt.
D. Risk for self-directed violence related to depression: This is the most appropriate nursing diagnosis following a suicide attempt, as it directly addresses the client’s risk of harm to themselves.
Correct Answer is D
Explanation
A. Sit with the client for a few minutes. While providing comfort is important, it does not address the immediate need to evaluate and manage a potentially serious condition.
B. Administer an analgesic. Administering analgesics without assessing the cause of the headache might mask symptoms of a serious issue. This is not the priority action.
C. Inform the nurse manager. Informing the nurse manager is important but does not directly address the client’s immediate needs or potential emergency.
D. Call the health care provider immediately. Reporting severe headache in a client with a cerebral aneurysm is critical as it could indicate worsening of the condition, such as aneurysm rupture or increased intracranial pressure. Immediate action is required to prevent further complications.
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