Which of the following assessment findings in a client with leukemia would indicate that the cancer has invaded the brain?
a. Headache and vomiting.
b. Restlessness and tachycardia
c. Hypervigilant and anxious behavior
d. Increased heart rate and decreased blood pressure.
Answer: a
Explanation: The usual effect of leukemic infiltration of the brain is increased intracranial pressure. The proliferation of cells interferes with the flow of cerebrospinal fluid in the subarachnoid space and at the base of the brain. The increased fluid pressure causes dilation of the ventricles, which creates symptoms of severe headache, vomiting, irritability, lethargy, increased blood pressure, decreased heart rate, and eventually, coma. Often children with a variety of illnesses are hypervigilant and anxious when hospitalized.
You might also like to view...
The yellowing of the lens in the aging eye may cause
a. Inaccurate color perception b. Excessive eye dryness c. Constricted pupils d. Diminished visual accommodation
The nurse observes that an adolescent client relates, reacts, and consistently behaves with one of the male staff in an inappropriate manner. Based on the adolescent's history, the nurse is concerned this client may be:
1. Manifesting manic behavior. 2. Experiencing a side effect from the medication. 3. Acting out a life script. 4. Afraid of being alone.
A patient has come to the clinic for a follow-up assessment. Before taking the blood pressure, the nurse should determine if the patient has:
A) Tried to rest quietly for 5 minutes before the reading is taken B) Refrained from smoking for at least 8 hours C) Been NPO for at least 2 hours D) Avoided drinking coffee for 12 hours before the visit
An equivalent measure for 5 mL is
A. 3 dr. B. 1 tbsp. C. 1 tsp. D. 2 gr.