The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?

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: 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.

Correct Answer: A

Rationale: With a WBC count of 3,000/ul (indicating leukopenia or low white blood cell count), the priority nursing intervention should be preventing infection. Leukopenia puts the client at a higher risk of developing infections due to a compromised immune system. Nurses should focus on implementing strict infection control measures, such as hand hygiene, maintaining a sterile environment, and promoting vaccination compliance to reduce the risk of infection for the hospitalized client. This intervention is crucial for ensuring the client's safety and well-being during their hospital stay. Alleviating pain, controlling infection, and monitoring blood transfusion reactions are important aspects of care but in this scenario, preventing infection takes precedence due to the client's low WBC count.

Correct Answer: C

Rationale: The most significant symptoms of Hodgkin's disease with category B classification are fever, weight loss, and night sweats. Night sweats are particularly characteristic of Hodgkin's disease and are considered one of the B symptoms along with fever and weight loss. Anemia and thrombocytopenia are not typically classified as specific symptoms of Hodgkin's disease category B.