Which initial assessment finding(s) would the nurse expect in a client diagnosed with acute lymphocytic leukemia (ALL)?
Petechiae and epistaxis
Generalized edema and rash
Alopecia and pallor
Bradycardia and lethargy
The Correct Answer is A
A. Petechiae (small red or purple spots caused by bleeding under the skin) and epistaxis (nosebleeds) result from thrombocytopenia, which is a low platelet count often seen in leukemia. The compromised bone marrow function leads to inadequate production of platelets, resulting in bleeding and bruising.
B. While generalized edema and rash can occur in various conditions, they are not specific to ALL and are not common initial findings. Edema might be seen in certain contexts (e.g., renal involvement or fluid overload), but it is not a hallmark of ALL.
C. Alopecia (hair loss) and pallor (paleness) can occur in clients undergoing chemotherapy for ALL, but they are not typically initial findings at the time of diagnosis. Pallor may result from anemia, which can develop as a consequence of the disease, but it is not the most immediate or characteristic symptom of ALL.
D. Bradycardia (slow heart rate) and lethargy are not typical initial findings of ALL. Lethargy could be present due to anemia or other systemic effects, but bradycardia is not commonly associated with the disease and would require further investigation for other underlying causes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. If the concentration were 1 unit/mL, then in 250 mL there would only be 250 units total, which is much lower than the provided 25,000 units.
B. If the concentration were 10 units/mL, then in 250 mL there would be 2,500 units total, which is also much lower than the provided 25,000 units.
C. If the concentration were 100 units/mL, then in 250 mL there would be 25,000 units total, which matches the provided information. However, while this seems plausible, it is not the answer we calculated.
D. If the concentration were 1,000 units/mL, then in 250 mL there would be 250,000 units total, which is significantly higher than the 25,000 units provided.
Correct Answer is D
Explanation
A. This statement is not advisable. While it is essential to avoid strenuous activity initially, gentle arm exercises and range-of-motion activities are generally encouraged as soon as possible to promote circulation and help prevent lymphedema. Immobilization can actually increase the risk of lymphedema.
B. This intervention is not recommended for preventing lymphedema. Sleeping on the side of the surgery (in this case, the left side) can put pressure on the affected arm and may not promote proper lymphatic drainage. Clients are often advised to sleep on their back or to position themselves in a way that does not compress the affected arm.
C. This intervention can provide temporary relief if there is swelling or discomfort, but it does not effectively prevent lymphedema. While cool compresses might help reduce inflammation, they are not a primary measure for lymphedema prevention.
D. This is the most effective intervention for preventing lymphedema. Elevating the affected arm helps facilitate lymphatic drainage and reduces the risk of fluid accumulation. Keeping the arm elevated above heart level encourages proper circulation and helps manage swelling.
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