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 B
Explanation
A. Limiting fluids with meals is not a recommended practice for preventing prostatitis. Staying hydrated is generally encouraged to promote urinary health. This option does not address the prevention of prostatitis recurrence.
B. This is a good instruction. Frequent voiding helps reduce the risk of urinary stasis and potential bacterial growth in the urinary tract, which can contribute to prostatitis. Encouraging the client to empty their bladder regularly is beneficial in preventing recurrence.
C. While monitoring PSA levels can be important for assessing prostate health, it is not a direct preventive measure for prostatitis recurrence. PSA tests are primarily used to screen for prostate cancer or monitor prostate conditions rather than prevent prostatitis itself.
D. This recommendation is not appropriate for preventing prostatitis. While caffeine may irritate the bladder and prostate, decaffeinated drinks typically do not have the same effect and can be a good source of hydration. Avoiding decaffeinated drinks does not contribute to prostatitis prevention.
Correct Answer is A
Explanation
A. This response is relevant and helps assess the characteristics of the lump. Pain can be an important factor in differentiating between conditions, such as epididymitis, testicular torsion, or tumors. However, while it is a useful question, it may not provide a comprehensive assessment of the situation.
B. This question can be relevant depending on the underlying cause of the lump. Issues with urination may suggest a problem related to the prostate or bladder rather than the testicle itself. While it can help assess urinary tract involvement, it may not directly address the significance of the lump in the testicle.
C. This question is important in the context of sexually transmitted infections (STIs), which can cause scrotal swelling or lumps due to conditions like epididymitis or orchitis. However, it does not directly assess the lump itself, making it less focused on the immediate concern.
D. This question addresses the possibility of an STI and related conditions. While it is relevant, it is not the best immediate question concerning the lump in the testicle. The presence of discharge may not directly correlate with the testicular lump itself.
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