The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?
Degree of upper body vasculature observed.
Arm circumference and degree of edema.
Blood pressure and heart rate.
Peripheral sensation and movement of upper extremities.
The Correct Answer is C
A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.
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Correct Answer is C
Explanation
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B. Babysitting a young child may expose the client to infections, which is not safe for someone with neutropenia. This statement shows a lack of understanding.
C. Calling the oncologist when experiencing an increased temperature is critical because it may indicate an infection, which is a major concern for clients with neutropenia. This statement reflects an appropriate understanding of the condition.
D. While wearing a mask can be beneficial in some situations, stating that it must be worn at all times is not necessary and shows a misunderstanding of the guidelines for reducing infection risk in neutropenia.
Correct Answer is B
Explanation
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C. While some precautions may be necessary, limiting time with others at home is not typically a requirement for external radiation, as it does not make the client radioactive.
D. Skin damage can occur from radiation treatment, and any changes should be reported to the healthcare provider, as monitoring and managing side effects is important for the patient's overall care.