For a client with Hodgkin disease who has developed neutropenia, what is an appropriate nursing intervention to include in the care plan?
Monitoring temperature every 4 hours
Omitting fresh fruits and vegetables from the diet
Positioning the client to increase lung expansion
Avoiding intramuscular (IM) injections
The Correct Answer is A
Reasoning:
Choice A reason: Monitoring temperature every 4 hours is critical in neutropenia, a common complication of Hodgkin disease treatment. Low neutrophil counts increase infection risk, and fever is an early sign of infection. Regular temperature checks enable prompt detection and treatment of infections, preventing sepsis in immunocompromised clients.
Choice B reason: Omitting fresh fruits and vegetables is not universally recommended for neutropenia. While some diets limit raw produce to reduce bacterial exposure, this is less critical than fever monitoring. Neutropenic precautions focus on infection prevention, with temperature monitoring being a more direct and urgent intervention.
Choice C reason: Positioning to increase lung expansion is relevant for respiratory conditions but not a priority in neutropenia. Neutropenia increases infection risk, not respiratory compromise. Monitoring for fever is more critical, as infections are the primary concern in clients with low neutrophil counts from Hodgkin disease therapy.
Choice D reason: Avoiding IM injections is important in neutropenia to reduce infection risk at injection sites, but it is secondary to fever monitoring. Injections can introduce bacteria, but fever detection through regular temperature checks is a more proactive and essential intervention for early infection identification in neutropenic clients.
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Related Questions
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Systolic blood pressure above 70 mm Hg is a goal in hypovolemia but is not the most specific outcome for DIC-related bleeding. While low blood pressure reflects fluid loss, addressing bleeding directly prevents further volume depletion, making reduced bleeding a more targeted and measurable outcome.
Choice B reason: A stable level of consciousness is important but not directly tied to deficient fluid volume from bleeding in DIC. Altered consciousness may result from cerebral ischemia or hyponatremia, but reducing bleeding is the primary goal to stabilize fluid volume and prevent further hemodynamic compromise.
Choice C reason: Urine output of 30 mL/hour or more indicates adequate renal perfusion but is a secondary outcome in DIC-related bleeding. While it reflects fluid status, directly addressing bleeding through interventions like transfusions or clotting factor replacement is more specific to correcting the underlying fluid volume deficit.
Choice D reason: Decreased bleeding is the most appropriate outcome for deficient fluid volume in DIC, as bleeding from mucosal and venipuncture sites directly causes volume loss. Reducing hemorrhage through platelet or factor replacement stabilizes fluid volume, preventing hypovolemia and its complications, making this the most measurable and relevant outcome.
Correct Answer is ["B","C","E"]
Explanation
Reasoning:
Choice A reason: Weight loss is not a typical side effect of corticosteroid therapy for Addison’s disease. Corticosteroids mimic cortisol, promoting weight gain through increased appetite and fat redistribution. Weight loss is more common in untreated Addison’s disease due to cortisol deficiency and reduced appetite.
Choice B reason: Poor wound healing is a side effect of corticosteroids, as they suppress immune responses and inhibit collagen synthesis. This impairs fibroblast activity and tissue repair, increasing infection risk and delaying wound closure, a significant concern for patients on long-term therapy for Addison’s disease.
Choice C reason: Hypertension is a common side effect of corticosteroids due to their mineralocorticoid effects, which increase sodium and water retention, elevating blood volume and pressure. This is particularly relevant in Addison’s disease treatment, where corticosteroids restore deficient aldosterone and cortisol, potentially causing fluid overload.
Choice D reason: Hypotension is not a side effect of corticosteroid therapy but a symptom of untreated Addison’s disease due to aldosterone deficiency, causing sodium loss and hypovolemia. Corticosteroid therapy corrects this, so hypotension is unlikely unless under-dosed or during acute crisis.
Choice E reason: Alterations in glucose metabolism are a side effect of corticosteroids, which induce insulin resistance and increase gluconeogenesis, leading to hyperglycemia. In Addison’s disease, corticosteroids replace deficient cortisol, but excess dosing can mimic Cushing’s syndrome, causing elevated blood glucose and requiring careful monitoring.
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