A patient with acute lymphoblastic leukemia (ALL) is admitted for chemotherapy treatment. As part of the nursing management, which of the following interventions is most critical to prevent infection in this patient?

Choice A Reason:

The client’s tongue is not relevant for diagnosing cataracts. Cataracts are an eye condition characterized by clouding of the lens, which affects vision. The tongue does not provide any information related to the presence of cataracts.

Choice B Reason:

The client’s eyelid is also not relevant for diagnosing cataracts. While the eyelid can be examined for other eye-related conditions, it does not provide information about the lens’s clarity or the presence of cataracts. Cataracts specifically affect the lens inside the eye.

Choice C Reason:

The lens of the client’s eye is the correct area to examine for diagnosing cataracts. Cataracts cause the lens to become cloudy, leading to symptoms such as blurred vision, difficulty seeing at night, and sensitivity to light. An eye examination, including a slit-lamp exam, allows the healthcare provider to see the lens and identify any cloudiness or opacities indicative of cataracts.

Choice D Reason:

The posterior pharynx of the client’s throat is not relevant for diagnosing cataracts. This area is examined for conditions related to the throat and respiratory system, not for eye conditions. Cataracts are diagnosed through an eye examination focusing on the lens.

Choice A Reason:

Encouraging a high-sodium diet is essential for patients with Addison’s disease because they often suffer from hyponatremia (low sodium levels) due to the lack of aldosterone, a hormone that helps regulate sodium and potassium balance. Increasing sodium intake helps to counteract this deficiency and maintain proper electrolyte balance.

Choice B Reason:

Administering potassium supplements is not recommended for patients with Addison’s disease because they already have hyperkalemia (high potassium levels) due to the lack of aldosterone. Adding more potassium could exacerbate this condition and lead to serious complications such as cardiac arrhythmias.

Choice C Reason:

Administering intravenous corticosteroids is a critical intervention for managing Addison’s disease, especially during an adrenal crisis. Corticosteroids like hydrocortisone help replace the deficient hormones and stabilize the patient’s condition by reducing inflammation and supporting metabolic functions.

Choice D Reason:

Monitoring blood glucose levels regularly is important because patients with Addison’s disease can experience hypoglycemia (low blood sugar levels) due to cortisol deficiency. Regular monitoring helps in timely detection and management of hypoglycemia, preventing potential complications.

Choice E Reason:

Administering diuretics is not appropriate for patients with Addison’s disease as it can lead to further electrolyte imbalances, particularly worsening hyponatremia and hyperkalemia. Diuretics increase the excretion of sodium and potassium, which is counterproductive in managing Addison’s disease.