The client has developed graft versus host disease (GVHD) during treatment for acute lymphoblastic leukemia (ALL). The client has a generalized pruritic rash on the trunk and the extremities. What nursing measures should the nurse use to address this problem?
Apply bacitracin liberally to the affected areas
Request a medical prescription for diphenhydramine or hydroxyzine
Instruct client to shower with cool water and use a mild soap
Clip fingernails and encourage the use of prescribed lotions
Correct Answer : B,C,D
A. Bacitracin is an antibiotic ointment typically used to prevent or treat bacterial infections in minor cuts and scrapes. It is not appropriate for treating a pruritic rash associated with GVHD. The rash may not be due to an infection but rather an immune response, so using bacitracin would not address the underlying issue.
B. Diphenhydramine (Benadryl) and hydroxyzine are antihistamines that can help alleviate itching and provide relief from pruritus. Requesting a prescription for one of these medications is an appropriate response to manage the symptoms of GVHD.
C. Showering with cool water can soothe irritated skin and reduce itching. Using mild soap helps to avoid further irritation or dryness that harsher soaps can cause. This intervention supports skin care and helps manage pruritus effectively.
D. Clipping fingernails can help prevent skin damage from scratching, which could lead to secondary infections. Encouraging the use of prescribed lotions can help keep the skin moisturized and alleviate dryness, further addressing the pruritus associated with GVHD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A negative output would imply that the client has produced less urine than the irrigation received, which is not the case here.
B. The true urine output is 675 mL, calculated by subtracting the irrigation amount from the total urine collected.
C. The calculation does not support this value, as it does not accurately reflect the total urine output after accounting for the irrigation.
D. Similar to option A, a negative value does not apply here since the urine output exceeds the irrigation amount.
Correct Answer is B
Explanation
A.While it's important to gather information about the client's symptoms, the priority in this situation is to determine the underlying cause of the neurological symptoms. A CT scan can quickly identify if there's been a stroke or other brain injury.
B.This is the most appropriate and urgent intervention. A CT scan can rapidly identify if the client has had a stroke, which is a time-sensitive medical emergency. Early diagnosis and treatment are crucial for minimizing brain damage and improving outcomes.
C.t-PA is a medication used to dissolve blood clots in the brain, but it is only effective if given within a specific time window after the onset of stroke symptoms. Without a confirmed diagnosis of stroke from a CT scan, administering t-PA could be harmful.
D.While a speech pathologist may be involved in the client's care later on, the priority is to determine the underlying cause of the neurological symptoms and initiate appropriate treatment. A CT scan is essential for this purpose.
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