A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?

Administer a saline enema for constipation.

Initiate contact precautions.

Encourage independence in the completion of ADLs.

Monitor oral mucosa daily.

Answer and Explanation

The Correct Answer is D

A. Administer a saline enema for constipation. Administering a saline enema may be necessary for constipation, but it is not directly related to managing bone marrow suppression.

B. Initiate contact precautions. Contact precautions are typically used for infectious diseases. In clients with bone marrow suppression, neutropenic precautions are more appropriate to prevent infections.

C. Encourage independence in the completion of ADLs. While promoting independence is important, clients with bone marrow suppression may be fatigued or immunocompromised, requiring assistance to reduce infection risk and conserve energy.

D. Monitor oral mucosa daily. Monitoring oral mucosa daily is crucial because clients with bone marrow suppression are at risk for mucositis, which can lead to infection and impact nutrition and hydration.

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Correct Answer is D

Explanation

A. Normal pessimism of the elderly: This statement downplays the seriousness of the client’s feelings. Although some elderly individuals may experience sadness, these statements suggest a deeper issue that should not be considered normal.

B. A cry for sympathy: This response dismisses the client's feelings as attention-seeking, which could lead to missing a serious issue, such as depression or suicidal ideation.

C. Normal grieving: While grief can lead to feelings of sadness, the statements indicate a broader sense of hopelessness and worthlessness, which goes beyond normal grieving.

D. Evidence of high suicide potential: The client’s statements suggest feelings of hopelessness and despair, which are red flags for suicide risk, especially in elderly clients. This requires immediate assessment and intervention.

A. Pharmacotherapy B. Client safety C. Cognitive-behavioral therapy D. Distraction therapy

Correct Answer is B

Explanation

A. Pharmacotherapy: While medication is crucial in managing bipolar disorder, the immediate priority during a manic episode is ensuring the client's safety, as they may engage in risky behavior.

B. Client safety: Client safety is the highest priority during a manic episode, as clients may act impulsively, which can lead to harm to themselves or others.

C. Cognitive-behavioral therapy: CBT is an important therapeutic intervention for long-term management, but it is not the immediate priority during a manic episode.

D. Distraction therapy: Distraction techniques can be helpful, but they are not a priority compared to ensuring the client’s safety.

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A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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