A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue.

Which of the following interventions should the nurse plan to include?

Increase protein in the diet.

Increase the client's fluids to 4 L per day.

Encourage the client to have continual bed rest.

Encourage strength-training exercise.

Answer and Explanation

The Correct Answer is A

A. Protein supports tissue repair, maintains muscle mass, and provides sustained energy. Leukemia and its treatments can lead to muscle wasting and general weakness, so additional protein can help counteract these effects and improve energy levels. It is also essential for immune support as well.

B. Increasing fluids to 4 L per day is generally excessive and may not be appropriate for this client. Excessive fluid intake can place strain on the cardiovascular system, which could be problematic, especially if the client is receiving chemotherapy or other treatments that may impact fluid balance.

C. Continual bed rest is not recommended, as it can contribute to deconditioning, muscle atrophy, and worsening fatigue over time. While rest periods are essential for clients experiencing fatigue, it is equally important to incorporate balanced, low-intensity activity to maintain strength and circulation.

D. Such exercises require significant energy and exertion, which might not be tolerable and could exacerbate fatigue. Instead, gentle, low-impact activities like walking or stretching are more appropriate for maintaining function without overwhelming the client’s energy reserves.

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Correct Answer is C

Explanation

Delirium is a state of acute confusion and cognitive impairment that can cause disorientation and difficulty with time perception. Reminding the client of the day and time frequently helps provide orientation and reduce confusion. It can help ground the client in reality and improve their understanding of their current circumstances.

Avoiding discussing the client's fears can hinder their ability to express and address their concerns. It is important to provide a safe and supportive environment where the client can communicate their fears and feelings.

Offering the client several choices at mealtimes might be overwhelming and confusing for someone experiencing delirium. It is generally better to provide structure and simplicity in their meal options, reducing decision-making demands.

Alternating daily caregivers can disrupt continuity of care and increase the client's confusion. Consistency in the caregiving team can help establish a therapeutic relationship and familiarity, which can aid in managing delirium.

A. Chemotherapy treatments B. Medications for a cardiac anomaly C. Clear rhinorrhea D. Two diarrhea stools in the last day

Correct Answer is A

Explanation

Chemotherapy treatments, which are used to treat cancer, can suppress the immune system and weaken the body's ability to respond to vaccines. As a result, receiving a live attenuated vaccine like the varicella immunization can pose a risk of severe complications for individuals undergoing chemotherapy. Therefore, it is contraindicated to administer the varicella vaccine in this case.

Medications for a cardiac anomaly, clear rhinorrhea, and two diarrhea stools in the last day are not contraindications for receiving a varicella immunization.

While medications for a cardiac anomaly and certain medical conditions may require special consideration or precautions when administering vaccines, they are not absolute contraindications for the varicella vaccine. The decision to administer the vaccine would depend on the individual's specific circumstances and the healthcare provider's assessment. Clear rhinorrhea (runny nose) and two diarrhea stools in the last day are considered minor illnesses and do not contraindicate the varicella vaccine. Generally, mild illnesses without fever or systemic symptoms do not pose a significant risk when receiving vaccines. However, it is always important to assess the overall health status of the individual and consult with a healthcare provider if there are concerns.

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A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue. Which of the following interventions should the nurse plan to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

Correct Answer is A

Explanation

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A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue.

Which of the following interventions should the nurse plan to include?