Rated A
"In formulating a nursing diagnosis of risk for
infection for a client with chronic lymphoid The nurse analyzes the laboratory values of a
leukemia (CLL), nursing measures should child with leukemia who is receiving
include: (Select all that apply.) chemotherapy . The nurse notes that the platelet
"A. Maintaining a clean technique for all invasive count is 20,000/ul. Based on the laboratry result,
procedures. which intervention will the nurse document in the
B. Placing the client in protective isolation. plan of care?
C. Limiting visitors who have colds and 1 Mointor closely for signs of infection 2. Mointor
infections. the temperature every 4hours 3. Initate prptective
D. Ensuring meticulous handwashing by all isolation precautions 4. Use soft small toothbrush
persons coming in contact with the client." - for mouth care - -Correct Ans 4 If a child is
-"Correct Answers: B, C, D severely thrombocytopenic and has a platelet
Rationale: Chronic lymphoid leukemia (CLL) is count less than 20,000/ul, bleeding precautions
characterized by a proliferation and accumulation need to be initated because of increased risk of
of small, abnormal mature lymphocytes in bone bleeding or hemorrhage. Options 1,2,3 are
marrow, peripheral blood, and body tissues. related to the prevention of infection rather than
Infections and fever are frequent complications of bleeding
CLL."
"A client with acute leukemia is admitted to the
"The client diagnosed with leukemia has central oncology unit. Which
nervous system involvement. Whichinstructions of the following would be most important for the
should the nurse teach? nurse to inquire?
"1.Sleep with the head of the bed elevated to "a. ""Have you noticed a change in sleeping
prevent increased intracranial pressure. habits recently?""
2.Take an analgesic medication for pain only b. ""Have you had a respiratory infection in the
when the pain becomes severe. last 6 months?""
3.Explain that radiation therapy to the head may c. ""Have you lost weight recently?""
result in permanent hair loss. d. ""Have you noticed changes in your
4.Discuss end-of-life decisions prior to cognitive alertness?""" - -Answer B is correct. The
deterioration" - -"Correct: 3 client with leukemia is at risk for infection and has
1.Sleeping with the head of the bed often had recurrent respiratory infections during
elevatedmight relieve some intracranial pressure, the previous 6 months. Insomnolence, weight
but it will not prevent intracranial pressure from loss, and a decrease in alertness also occur in
occurring.2.Analgesic medications for clients with leukemia, but bleeding tendencies and infections
cancer are given on a scheduled basis with a are the primary clinical manifestations; therefore,
fast-acting analgesic administered PRN for answers A, C, and D are incorrect.
break-through pain.3.Radiation therapy to the
head and scalp area is the treatment of choice
for central nervous system involvement of any "What nursing diagnosis is seen with acute
cancer. If the radiation therapy destroys the hair lymphocytic leukemia and thromocytopenia?
follicle, the hair will not grow back.4.Cognitive "A. potential for injury
deterioration does not usually occur" B. self-care deficit
C. potential for self harm
, Leukemia & Hodgkins NCLEX Test Questions and Answers
Rated A
D. alteration in comfort" - -"Answer: A growth in relation to chemotherapy?
potential for injury "1. Faster growing cells are less susceptible to
Low platelet increases risk of bleeding from even chemotherapy.
minor injuries. Safety measures: shave with an 2. Nondividing cells are more susceptible to
electric razor, use soft tooth brush, avoid SQ or chemotherapy.
IM meds and invasive procedures (urinary 3. Faster growing cells are more susceptible to
drainage catheter or a nasogastric tube), side- chemotherapy.
rails up, remove sharp objects, frequently assess 4. Slower growing cells are more susceptible to
for signs of bleeding, bruising, hemorrhage. " chemotherapy." - -"Answer 3
The faster the cell grows, the more susceptible it
is to chemotherapy and radiation therapy. Slow-
Which of the following manifestations would be growing and nondividing cells are less
directly associated with Hodgkin's disease? susceptible to chemotherapy. Repeated cycles of
"a. bone pain chemotherapy are used to destroy nondividing
b. generalized edema cells as the begin active cell division."
c. petechiae and purpura
d. painless, enlarged lymph nodes" - -
"Correct answer: D The client is admitted to the hospital with a
Rationale: Hodgkin's disease usually presents as suspected diagnosis of Hodgkin's disease. Which
painless enlarged lymph nodes. The diagnosis is assessment finding would the nurse expect to
made by lymph node biopsy." note specifically in the client? "a) fatigue
b) weakness
c) weight gain
"When caring for a client with a diagnosis of d) enlarged lymph nodes" - -"D
thrombocytopenia, the nurse should plan to:
"a.Discourage the use of stool softeners - Hodgkin's disease is a chronic progressive
b.Assess temperature readings every six hours neoplastic disorder of lymphoid tissue
c.Avoid invasive procedures characterized by the painless enlargement of
d.Encourage the use of a hard, brittle toothbrush lymph nodes with progression to extralymphatic
sites, such as the spleen and liver. Weight loss is
"- -"Answer: C most likely to be noted. Fatigue and weakness
Rationale: may occur but are not related significantly to the
disease."
Thrombocytopenia is a deficiency of platelets,
and leaves the patient more prone to
hemmorrhage. For this reason, avoiding invasive "The nurse is caring for a client diagnosed with
procedures will limit the risk of hemorrhage. Stoolacute myeloid leukemia. Which assess-ment data
softeners should be encouraged, while hard warrant immediate intervention?
brittle toothbrushes should be avoided. 1.T 99, P 102, R 22, and BP 132/68.
Temperature is not the most important vital to 2.Hyperplasia of the gums.
track in this patient" 3.Weakness and fatigue.
4.Pain in the left upper quadrant." - -
"Correct: 4
"Which statement is correct about the rate of cell 1.These vital signs are not alarming. The