The child is receiving chemotherapy for acute lymphocytic leukemia. The nurse should monitor the child for which of the following signs of tumor lysis syndrome?
1. Thrombocytopenia and leukocytosis
2. Oliguria and altered levels of consciousness
3. Respiratory distress and cyanosis
4. Upper-extremity edema and neck vein distension
2
Rationale:
1. Thrombocytopenia and leukocytosis occur with a hematological emergency.
2. Tumor lysis causes a metabolic emergency. Because of electrolyte imbalance, the signs can be oliguria and altered levels of consciousness.
3. Space-occupying lesions can cause respiratory distress and cyanosis.
4. Space-occupying lesions can cause upper-extremity edema and neck vein distension.
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The nurse collects a nursing history from a patient who says she keeps so busy she often ignores the need to defecate. The nurse explains the danger of this behavior is what?
A) External sphincter will require more distention to stimulate reflex B) Incontinence of stool due to loss of sphincter control C) Diarrhea D) Malabsorption of nutrients from the colon
A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? Select all that apply
A) Perforation into the mediastinum B) Development of an esophageal lesion C) Erosion into the great vessels D) Painful swallowing E) Obstruction of the esophagus
Consumers of health care are responsible for
A. communicating honestly with the physician and others providing care. B. withholding sensitive, personal health information from health care providers. C. selecting the individuals who will care for them during the hospitalization. D. abiding by the physicians' treatment decisions.
An advanced practice nurse (in a state where the nurse can sign the first certification for an emergency commitment) evaluates a client for emergency commitment because of the likelihood the client will do serious harm to others
The client threatened to kill her mother, who she thinks is "against her." In assessing the need for commitment, what opening would be most facilitative? 1. "Tell me about your delusions." 2. "I understand you have had some difficulty today." 3. "You have threatened your mother. Tell me why." 4. "Because you threatened your mother, you are going to have to go to the hospi-tal."