BIOLOGY 102. Medical-Surgical Nursing Critical Thinking in Client Care, CHAPTER 34

Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

CHAPTER   34

Chapter 34

1.            What actions should the nurse anticipate taking first when a young female’s lab findings come back with microcytic and hypochromic red blood cells (RBCs)?

1.    Place the client on ‘nothing by mouth” (n.p.o.) status in anticipation of emergency surgery due to an acute hemorrhagic event.

2.    Start an IV for replacement fluids, such as D5W or D5NS.

3.    Consult with the dietitian to develop a diet that is high in iron products.

4.    Assess the past history further for previous risks of bleeding or menstrual changes.

Bloom’s:      Analysis

Nursing Process: Interventions

Client Needs: Physiological Integrity: Physiological Adaptation

2.            A client’s lab shows larger, oval-shaped, macrocytic red blood cells (RBCs)            with thin membranes present. In addition, the client is complaining of paresthesia

                and proprioception. Which therapy would the nurse expect to be included in the             discharge plan?

                1.    A diet higher in green, leafy vegetables; broccoli; wheat germ; and asparagus

                2.    A daily multivitamin with extra iron

                3.    Instructions about subcutaneous injections of erythropoietin for a few weeks

                4.    Instructions about intramuscular parenteral injections of B₁₂ (Anacobin) orCyanocobalamin for the rest of her life

3.            A client is admitted with the diagnosis of sickle-cell crisis. Which of these tasks would the nurse perform first based upon the following clinical findings: temperature 102°F, O₂ saturation of 89%, and complaints of severe abdominal pain?

                1.    Give Tylenol (acetaminophen) grains X (650 mg).

                2.    Apply oxygen per nasal cannula @ 3L/minute.

                3.    Administer morphine sulfate grain ¼ intramuscular.

                4.    Assess and document peripheral pulses.

4.            After several doses of chemotherapy, a client complains of fatigue, pallor,           progressive weakness, exertional dyspnea, headache, and tachycardia. Which NANDA nursing diagnosis would the nurse list as the first priority?

                1.    Nutrition, imbalanced: less than body requirements

                2.    Activity Intolerance

                3.    Powerlessness

                4.    Coping, Ineffective

5.            When evaluating a client’s understanding about dietary needs following a dietary            consult that covered home management of dietary deficiency anemia, which               statement by the client would indicate a need for additional teaching?

                1.    “I will eat more fruits, vegetables, especially green, leafy ones, to get more B₁₂ in my diet.”

                2.    “I will take vitamins with extra iron in addition to eating a balanced diet with meat to correct my anemia.”

                3.    “I will add food high in vitamin C to improve my absorption of iron in both my vitamins.”

                4.    “I will need to include more protein foods in my diet such as meats, dried beans, and whole-grain breads.”

6.            When assessing a client for acute myeloid leukemia (AML), the nurse would       include which action in the plan of care to minimize the risk of complications?

                1.    Extra precautions when “handling” the client and “strict hand hygiene”

                2.    Additional nutrition spaced frequently throughout the day to increase caloric intake

                3.    Restriction of fluids and salts to decrease edema

                4.    Regulation of the thermostat for a cooler environment

7.            A client who has just been diagnosed with chronic myeloid leukemia (CML) is discussing anticipatory grieving. Which action by the nurse would be inappropriate at this time?

                1.    Establish open communication and encourage sharing of feelings to discuss grieving.

                2.    Make referrals for support or bereavement groups.

                3.    Identify role changes and family stress management strategies.

                4.    Encourage the client to get affairs “in order” now to avoid waiting until it is too late.

Bloom’s: Application

Nursing Process: Planning

Client Needs: Psychosocial Integrity

8.            When assessing a client with malignant lymphoma, which understanding by the                nurse would be correct when trying to identify related symptoms?

                1.    Hodgkin’s has multiple nodes, including mesentery involvement.

                2.    Non-Hodgkin’s pattern of spread is diffuse and unpredictable.

                3.    Hodgkin’s has early extranodal involvement.

                4.    No weight loss is noted in non-Hodgkin’s.

9.            When a client has a bleeding tendency, such as with heparin-induced thrombocytopenia or hemophilia, which nursing action would be most appropriate?

                1.    Avoid invasive procedures, such as rectal temperatures, urinary       catheterizations, and parenteral injections.

                2.    Apply pressure to puncture sites for 3–5 minutes for arterial blood gases aspiration.

                3.    Give enemas to avoid straining when having a bowel movement.

                4.    Encourage client to brush teeth thoroughly and rinse with alcohol-based mouthwash after each meal.

10.          According to evidence-based practice for clients undergoing stem cell transplants, which NANDA nursing diagnoses would be appropriate? Select all that apply.

                1.    Coping, Ineffective

                2.    Fatigue

                3.    Family Processes, Interrupted

                4.    Infection Risk for

                5.    Fluid Imbalance, Excess