The client is 22 days post transplant from an allogeneic bone marrow transplantation. The nurse observes that the client's sclera and hard palate are yellow
Which additional clinical manifestation supports the possibility of veno-occlusive disease (VOD)? A. Weight gain of 8 pounds in the last 3 days
B. Total white blood cell count of 2000 per mm3
C. Six to 10 watery stools per day for the last 3 days
D. Hard, ropelike consistency of the peripheral vein proximal to the IV site
A
VOD occludes hepatic venules through thrombosis and phlebitis. The resulting decreased liver function causes the formation of ascites, weight gain, increased abdominal girth, liver enlarge-ment, and pain in the right upper quadrant.
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Although intact skin effectively protects an individual, it functions within physiological limits
Which qualities of healthy skin work synergistically within these limits to absorb, cushion against, deflect, or neutralize potentially harmful forces, as well as protect against potentially harmful substances that might impair skin integrity? (Select all that apply.) a. Strength b. Pliability c. Location d. Durability e. Moistness f. Pigmentation
The nurse is helping a patient with schizophrenia develop an exercise plan. The patient has obtained medical clearance for walking and light exercise. Which nursing interventions are the most appropriate? Select all that apply
1. Assess medication adherence. 2. Assess patient confidence level. 3. Provide memory prompts. 4. Provide reality orientation. 5. Assess body mass index.
The nursing manager of a surgical unit has been asked by administration to evaluate client outcomes post cardiac catheterization
Using data about client outcomes post cardiac catheterization for the past 6 months so as to modify practice is an example of: a. Information. b. Cost-effective care. c. Meeting standards. d. Evidence-based practice.
A nurse observes a patient with a history of aggressive behavior toward others pacing in the dayroom while appearing to talk to himself. The nurse will best intervene with this patient therapeutically by:
a. asking him to sit in the dayroom and watch television with the other patients and staff. b. instructing him to go to his room and remain there until he shows that he can be sociable. c. asking him if he would like to walk to his room where he and the nurse can sit together quietly to discuss the cause of his behavior. d. assigning an ancillary staff member the task of walking him around the unit for several minutes and then returning him to his room.