A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Correct Answer: D

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired clot formation and increased risk of bleeding. With a low platelet count, there is an increased risk of internal bleeding and hemorrhage, which can affect vital organs such as the brain, heart, and gastrointestinal tract. Therefore, the priority nursing diagnosis for a client with thrombocytopenia receiving chemotherapy would be Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Monitoring for signs of internal bleeding, such as changes in mental status, chest pain, and abdominal pain, is crucial to prevent potential life-threatening complications.

Correct Answer: B

Rationale: Polymyositis is a condition that involves inflammation of the muscles, including the muscles involved in swallowing (dysphagia) and breathing. This can lead to a higher risk of aspiration, where food or fluids go into the airway instead of the esophagus. Therefore, monitoring for signs and symptoms of aspiration and ensuring the client exhibits no signs of aspiration are crucial in the care of a client with polymyositis. The other options are not directly related to the potential problems associated with polymyositis and are more general aspects of nursing care.

Correct Answer: C

Rationale: The question is asking about the characteristics the nurse might expect to observe in Mr. Gil. Given the information provided, Mr. Gil's possible condition can be related to a slowly progressive deficit in intellect. This might manifest as cognitive decline, memory issues, and other intellectual challenges over an extended period of time. This description aligns with conditions such as dementia or Alzheimer's disease, which are characterized by a gradual decline in cognitive abilities rather than rapid deterioration (as in option B) or transient episodes (as in option A). Therefore, option C is the most likely characteristic the nurse could expect when observing Mr. Gil.

Correct Answer: A

Rationale: The appropriate action by the nurse is to observe the patient for abnormal bleeding. Warfarin is an anticoagulant medication, and one of its serious side effects is excessive bleeding. It is important for the nurse to monitor the patient closely for signs of abnormal bleeding, such as easy bruising, blood in urine or stool, or prolonged bleeding from cuts or wounds. This observation allows for early detection and intervention if any abnormal bleeding occurs. Notifications to the healthcare provider should also be made if abnormal bleeding is suspected. It is crucial not to make any changes to the warfarin dose or administer Vitamin K without a physician's order, as these actions can have serious consequences.

Correct Answer: C

Rationale: Patients with lymphoma are at higher risk for infections because their immune system is often compromised due to the disease itself or treatment such as chemotherapy. Going outside for a walk exposes the patient to various environmental factors including pathogens, bacteria, and viruses that can increase the risk of infections. In contrast, going to church, cleaning the house, and watching television do not necessarily pose the same level of risk for infection as being outside in the open air. It is therefore important for patients with lymphoma to avoid unnecessary exposure to potential sources of infection to reduce their risk of developing infections.