The nurse is caring for a patient who is admitted to a surgical unit after a thyroidectomy.
The nurse takes and maintains the inflated blood pressure cuff on the patient and observes a carpopedal spasm.
What does this result indicate to the nurse?

Choice A rationale

Pain from mucositis and oral tissue injury is a significant concern for patients undergoing chemotherapy. However, it is not typically life-threatening and can be managed with appropriate pain relief measures and oral care.

Choice B rationale

Weakness and fatigue with activity are common side effects of chemotherapy and the disease process itself. While these symptoms impact the patient's quality of life, they do not usually require urgent intervention.

Choice C rationale

Blood pressure of 90/64 mmHg, pulse of 102 beats per minute, and oral temperature of 38.5 degrees Celsius suggest possible sepsis or severe infection. These vital signs indicate an urgent need for intervention to prevent further deterioration and potentially life-threatening complications.

Choice D rationale

Scattered ecchymosis and petechiae are signs of thrombocytopenia (low platelet count), which is a common complication of leukemia and its treatment. While important to monitor and manage, these findings are not typically as urgent as signs of sepsis or severe infection.

Choice A rationale

Scheduling colonoscopy screening beginning at age 45 is an example of secondary prevention, which focuses on early detection of diseases in asymptomatic individuals. By identifying precancerous polyps or early-stage colorectal cancer, healthcare providers can intervene earlier, improving outcomes and reducing mortality rates associated with colorectal cancer.

Choice B rationale

Monitoring for signs of secondary malignancies is a part of tertiary prevention, which aims to manage and prevent complications in patients who already have a disease. It does not fit the criteria for secondary prevention, which focuses on early detection before symptoms appear.

Choice C rationale

Reducing consumption of processed meat and alcohol is a primary prevention strategy, aiming to lower the risk of developing cancer in the first place. Primary prevention focuses on preventing the onset of disease through lifestyle and environmental changes, rather than early detection and intervention.

Choice D rationale

Avoiding ultraviolet radiation with the use of sunscreen and sun-protective clothing is also a primary prevention strategy. It aims to prevent skin cancer by reducing exposure to harmful UV rays, thereby lowering the risk of developing cancer from sun damage. .