LEUKEMIA & HODGKINS NCLEX EXAM 2024/2025 WITH 100%
ACCURATE SOLUTIONS
"In formulating a nursing diagnosis of risk for infection for a
client with chronic lymphoid leukemia (CLL), nursing measures
should include: (Select all that apply.)
"A. Maintaining a clean technique for all invasive procedures.
B. Placing the client in protective isolation.
C. Limiting visitors who have colds and infections.
D. Ensuring meticulous handwashing by all persons coming in
contact with the client." - Answer "Correct Answers: B, C, D
Rationale: Chronic lymphoid leukemia (CLL) is characterized
by a proliferation and accumulation of small, abnormal mature
lymphocytes in bone marrow, peripheral blood, and body
tissues. Infections and fever are frequent complications of CLL."
"The client diagnosed with leukemia has central nervous system
involvement. Whichinstructions should the nurse teach?
"1.Sleep with the head of the bed elevated to prevent increased
intracranial pressure.
2.Take an analgesic medication for pain only when the pain
becomes severe.
3.Explain that radiation therapy to the head may result in
permanent hair loss.
,4.Discuss end-of-life decisions prior to cognitive deterioration" -
Answer "Correct: 3
1.Sleeping with the head of the bed elevatedmight relieve some
intracranial pressure, but it will not prevent intracranial pressure
from occurring.2.Analgesic medications for clients with cancer
are given on a scheduled basis with a fast-acting analgesic
administered PRN for break-through pain.3.Radiation therapy to
the head and scalp area is the treatment of choice for central
nervous system involvement of any cancer. If the radiation
therapy destroys the hair follicle, the hair will not grow
back.4.Cognitive deterioration does not usually occur"
The nurse analyzes the laboratory values of a child with
leukemia who is receiving chemotherapy . The nurse notes that
the platelet count is 20,000/ul. Based on the laboratry result,
which intervention will the nurse document in the plan of care?
1 Mointor closely for signs of infection 2. Mointor the
temperature every 4hours 3. Initate prptective isolation
precautions 4. Use soft small toothbrush for mouth care -
Answer Correct Ans 4 If a child is severely thrombocytopenic
and has a platelet count less than 20,000/ul, bleeding precautions
need to be initated because of increased risk of bleeding or
hemorrhage. Options 1,2,3 are related to the prevention of
infection rather than bleeding
,"A client with acute leukemia is admitted to the oncology unit.
Which
of the following would be most important for the nurse to
inquire?
"a. ""Have you noticed a change in sleeping habits recently?""
b. ""Have you had a respiratory infection in the last 6 months?""
c. ""Have you lost weight recently?""
d. ""Have you noticed changes in your alertness?""" - Answer
Answer B is correct. The client with leukemia is at risk for
infection and has often had recurrent respiratory infections
during the previous 6 months. Insomnolence, weight loss, and a
decrease in alertness also occur in leukemia, but bleeding
tendencies and infections are the primary clinical
manifestations; therefore, answers A, C, and D are incorrect.
"What nursing diagnosis is seen with acute lymphocytic
leukemia and thromocytopenia?
"A. potential for injury
B. self-care deficit
C. potential for self harm
D. alteration in comfort" - Answer "Answer: A potential for
injury
Low platelet increases risk of bleeding from even minor injuries.
Safety measures: shave with an electric razor, use soft tooth
, brush, avoid SQ or IM meds and invasive procedures (urinary
drainage catheter or a nasogastric tube), side-rails up, remove
sharp objects, frequently assess for signs of bleeding, bruising,
hemorrhage. "
Which of the following manifestations would be directly
associated with Hodgkin's disease?
"a. bone pain
b. generalized edema
c. petechiae and purpura
d. painless, enlarged lymph nodes" - Answer "Correct answer: D
Rationale: Hodgkin's disease usually presents as painless
enlarged lymph nodes. The diagnosis is made by lymph node
biopsy."
"When caring for a client with a diagnosis of thrombocytopenia,
the nurse should plan to:
"a.Discourage the use of stool softeners
b.Assess temperature readings every six hours
c.Avoid invasive procedures
d.Encourage the use of a hard, brittle toothbrush
" - Answer "Answer: C
ACCURATE SOLUTIONS
"In formulating a nursing diagnosis of risk for infection for a
client with chronic lymphoid leukemia (CLL), nursing measures
should include: (Select all that apply.)
"A. Maintaining a clean technique for all invasive procedures.
B. Placing the client in protective isolation.
C. Limiting visitors who have colds and infections.
D. Ensuring meticulous handwashing by all persons coming in
contact with the client." - Answer "Correct Answers: B, C, D
Rationale: Chronic lymphoid leukemia (CLL) is characterized
by a proliferation and accumulation of small, abnormal mature
lymphocytes in bone marrow, peripheral blood, and body
tissues. Infections and fever are frequent complications of CLL."
"The client diagnosed with leukemia has central nervous system
involvement. Whichinstructions should the nurse teach?
"1.Sleep with the head of the bed elevated to prevent increased
intracranial pressure.
2.Take an analgesic medication for pain only when the pain
becomes severe.
3.Explain that radiation therapy to the head may result in
permanent hair loss.
,4.Discuss end-of-life decisions prior to cognitive deterioration" -
Answer "Correct: 3
1.Sleeping with the head of the bed elevatedmight relieve some
intracranial pressure, but it will not prevent intracranial pressure
from occurring.2.Analgesic medications for clients with cancer
are given on a scheduled basis with a fast-acting analgesic
administered PRN for break-through pain.3.Radiation therapy to
the head and scalp area is the treatment of choice for central
nervous system involvement of any cancer. If the radiation
therapy destroys the hair follicle, the hair will not grow
back.4.Cognitive deterioration does not usually occur"
The nurse analyzes the laboratory values of a child with
leukemia who is receiving chemotherapy . The nurse notes that
the platelet count is 20,000/ul. Based on the laboratry result,
which intervention will the nurse document in the plan of care?
1 Mointor closely for signs of infection 2. Mointor the
temperature every 4hours 3. Initate prptective isolation
precautions 4. Use soft small toothbrush for mouth care -
Answer Correct Ans 4 If a child is severely thrombocytopenic
and has a platelet count less than 20,000/ul, bleeding precautions
need to be initated because of increased risk of bleeding or
hemorrhage. Options 1,2,3 are related to the prevention of
infection rather than bleeding
,"A client with acute leukemia is admitted to the oncology unit.
Which
of the following would be most important for the nurse to
inquire?
"a. ""Have you noticed a change in sleeping habits recently?""
b. ""Have you had a respiratory infection in the last 6 months?""
c. ""Have you lost weight recently?""
d. ""Have you noticed changes in your alertness?""" - Answer
Answer B is correct. The client with leukemia is at risk for
infection and has often had recurrent respiratory infections
during the previous 6 months. Insomnolence, weight loss, and a
decrease in alertness also occur in leukemia, but bleeding
tendencies and infections are the primary clinical
manifestations; therefore, answers A, C, and D are incorrect.
"What nursing diagnosis is seen with acute lymphocytic
leukemia and thromocytopenia?
"A. potential for injury
B. self-care deficit
C. potential for self harm
D. alteration in comfort" - Answer "Answer: A potential for
injury
Low platelet increases risk of bleeding from even minor injuries.
Safety measures: shave with an electric razor, use soft tooth
, brush, avoid SQ or IM meds and invasive procedures (urinary
drainage catheter or a nasogastric tube), side-rails up, remove
sharp objects, frequently assess for signs of bleeding, bruising,
hemorrhage. "
Which of the following manifestations would be directly
associated with Hodgkin's disease?
"a. bone pain
b. generalized edema
c. petechiae and purpura
d. painless, enlarged lymph nodes" - Answer "Correct answer: D
Rationale: Hodgkin's disease usually presents as painless
enlarged lymph nodes. The diagnosis is made by lymph node
biopsy."
"When caring for a client with a diagnosis of thrombocytopenia,
the nurse should plan to:
"a.Discourage the use of stool softeners
b.Assess temperature readings every six hours
c.Avoid invasive procedures
d.Encourage the use of a hard, brittle toothbrush
" - Answer "Answer: C
