The nurse is caring for a 78-year-old male with Hodgkin's disease who has received both chemotherapy and radiation. He was admitted to the hospital to evaluate an unexplained increasing fatigue and inability to care for himself
Nursing responsibilities include: Select all that apply. 1. Monitoring hemoglobin and hematocrit.
2. Spacing activities to allow for periods of rest.
3. Obtaining a nutrition consult.
4. Mobilizing the client every hour.
5. Limiting oral intake.
1. Monitoring hemoglobin and hematocrit.
2. Spacing activities to allow for periods of rest.
3. Obtaining a nutrition consult.
Rationale: Monitoring hemoglobin and hematocrit. Both cancer and cancer treatments cause bone marrow suppression, which decreases the hemoglobin and hematocrit. Therefore it is essential to monitor these values, in order to determine when replacement treatment is necessary. Spacing activities to allow for periods of rest. Cancer and cancer treatment can both cause fatigue. Clustering patient care activities together will allow for prolonged periods of rest for patients who are experiencing fatigue. Obtaining a nutrition consult. Since anorexia is such a common problem with cancer clients, having a nutrition consult would be advantageous. Mobilizing the client every hour. Since fatigue is a factor with cancer clients, mobilizing the client every hour would be contraindicated. Limiting oral intake. There is no reason to limit oral intake with this client.
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A client discusses with the nurse her fears of having sleep apnea. Which of the following statements made by the client is suggestive of sleep apnea?
A) "My legs jump and feel tingly off and on during the night." B) "I wake up and feel as if I have been choking." C) "I have a great deal of difficulty falling asleep every night." D) "I have to sleep on at least three pillows every night."
Assistive devices such as canes, crutches, and walkers are used for people who need to limit weight-bearing activities on joints. Which statement by a nurse best illustrates an understanding of the appropriate use of these devices?
a. "Canes provide minimal support and bal-ance and are carried on the unaffected side." b. "When using a cane, slide it as you go to decrease the arm strain." c. "A three-point gait is used when walking with a walker." d. "When using crutches, the unaffected leg goes down the steps first."
The nurse is caring for a 62-year-old African-American woman who has been placed on Coumadin. The nurse should expect the client's response to this medication to be:
a. greater than usual; she may respond exceptionally well to the medication. b. less than usual; she will probably have a decreased therapeutic effect. c. greater than usual; she should be monitored closely for bleeding irregularities. d. less than usual; she will tend to experience a hypersensitivity reaction.
Which of the following interventions by the nurse is most likely to have a positive influence on the client's adoption of a new healthy behavior?
A) Providing feedback about what the client is doing incorrectly B) Providing feedback about what the client is doing correctly C) Not providing feedback D) Not providing role modeling of the desired change