A nurse is providing teaching to a client who has neutropenia.
Which of the following information should the nurse include in the teaching?
Perform mild exercise, such as gardening.
Avoid crowds.
Eat plenty of fresh fruits and vegetables.
Take temperature weekly.
The Correct Answer is B
Choice A rationale
Gardening involves exposure to soil-borne microorganisms, fungi, and dust, which pose a significant infection risk for neutropenic clients whose compromised immune systems, characterized by a neutrophil count typically below 1.5 × 10^9/L (normal range 2.5–7.5 × 10^9/L), cannot effectively combat these environmental pathogens.
Choice B rationale
Avoiding crowds minimizes exposure to airborne pathogens, including viruses and bacteria, which are easily transmitted in close proximity. Neutropenic individuals have a severely impaired innate immune response due to a deficiency in neutrophils, making them highly susceptible to even common community-acquired infections. This reduces the pathogen load they encounter.
Choice C rationale
Fresh fruits and vegetables can harbor bacteria, molds, and pesticides on their surfaces, even after washing. For a neutropenic client, ingesting these microorganisms can lead to severe gastrointestinal infections or systemic sepsis due to the inability of their diminished neutrophil count to mount an adequate immune defense.
Choice D rationale
Taking temperature weekly is insufficient for monitoring neutropenia. A daily or even more frequent temperature assessment is crucial because fever (oral temperature >38.0°C or 100.4°F) is often the first and sometimes only sign of infection in neutropenic clients, necessitating immediate intervention given their immunocompromised state.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Discussing insurance coverage is beyond the nurse's scope of practice and does not address the immediate safety concern related to the elevated INR. The nurse's primary responsibility is patient safety and education regarding potential health risks, not financial implications. The client's autonomy in making healthcare decisions is paramount.
Choice B rationale
A client cannot be legally detained in a healthcare facility against their will, assuming they are of sound mind. Requiring a signed Against Medical Advice (AMA) form is a documentation process, not a prerequisite for discharge. Detaining a competent client constitutes false imprisonment, violating their civil liberties.
Choice C rationale
Asking security to guard the room is a restrictive action that infringes upon the client's autonomy and right to leave. This approach is coercive and may escalate the situation, potentially leading to a legal and ethical dilemma. It does not prioritize patient education or safety through explanation.
Choice D rationale
Explaining the risks associated with leaving against medical advice, especially with an elevated INR, is crucial for informed decision-making. An INR of 3.5 indicates increased bleeding risk (normal range 0.8-1.2 or 2.0-3.0 for therapeutic anticoagulation). Providing this scientific information allows the client to understand potential adverse physiological events.
Correct Answer is C
Explanation
Choice A rationale
Swelling of the extremities can occur due to various reasons, including immobility or fluid retention, and while it warrants assessment, it is not typically an immediate, life-threatening complication directly associated with brain cancer radiation therapy requiring urgent reporting unless accompanied by other severe symptoms.
Choice B rationale
Chest pain and dyspnea could indicate pulmonary embolism or cardiac complications, which are serious. However, in the context of brain cancer and radiation therapy, these are not the most immediate or direct life-threatening neurological manifestations specific to the brain that would require reporting first.
Choice C rationale
Seizures indicate abnormal electrical activity in the brain, often due to increased intracranial pressure (ICP) or direct cerebral irritation from the tumor or radiation-induced edema. This is an acute neurological emergency requiring immediate medical intervention to prevent further brain damage and manage airway protection.
Choice D rationale
Hematuria, or blood in the urine, suggests renal or urological issues. While important to investigate, it is not a direct or immediate neurological complication of brain cancer or its radiation therapy that would take precedence over acute neurological changes like seizures.
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