What is the major nursing intervention in educating clients who have leukemia?

Correct Answer: C

Rationale: The major nursing intervention in educating clients who have leukemia is to explain the need to limit exposure to those who are ill (Option C). This is crucial because individuals with leukemia have compromised immune systems, making them more susceptible to infections. By avoiding contact with sick individuals, the client reduces the risk of acquiring infections that could be life-threatening. Option A, monitoring temperature at least once per shift, is important in assessing for signs of infection but is not the major nursing intervention for educating clients with leukemia. Option B, implementing contact isolation precautions, may be necessary in certain situations but does not address the primary concern of limiting exposure to ill individuals. Option D, keeping the client warm as they chill easily, is not a priority compared to preventing infections through education on limiting exposure. In an educational context, it is essential for nurses caring for clients with leukemia to have a thorough understanding of the importance of infection prevention. Educating clients on strategies to reduce their risk of exposure to infectious agents is a key aspect of promoting their health and well-being while managing their condition. By providing this education, nurses empower clients to take an active role in safeguarding their health.

Correct Answer: B

Rationale: The correct answer is B) Practice conscientious hand washing. This nursing intervention is crucial in ensuring that a client with Hodgkin's disease remains free of infection because these individuals often have compromised immune systems due to the disease and its treatments. Proper hand hygiene helps prevent the spread of pathogens that could lead to infections, which can be particularly dangerous for immunocompromised patients like those with Hodgkin's disease. Option A) Apply ice to the skin for brief periods is not directly related to infection prevention in this context. While it may provide comfort for certain symptoms, it does not address the risk of infection that is the primary concern for these patients. Option C) Provide cool sponge baths is also not directly related to infection prevention. While maintaining good hygiene is important, the key focus for infection control lies in practices like hand washing that directly reduce the risk of introducing harmful pathogens to the patient. Option D) Use cotton gloves is not as effective as proper hand washing in preventing infection transmission. While gloves can be useful in certain situations, they are not a substitute for thorough hand hygiene practices, which are essential for reducing the risk of infections in patients with compromised immune systems like those with Hodgkin's disease. In an educational context, it is important for nurses to understand the rationale behind each intervention to provide safe and effective care to their patients. By emphasizing the significance of hand washing in infection control for immunocompromised individuals, nurses can help protect these vulnerable patients from potential harm and improve their overall quality of care.

Correct Answer: B

Rationale: The correct answer is B) Use mild soap. When dealing with a client with Hodgkin's disease at risk of impaired skin integrity, it's important to recommend using mild soap to prevent skin irritation and damage. Strong or harsh soaps can strip the skin of its natural oils, leading to dryness and increased susceptibility to breakdown. A) Do not trim nails - While it's important to avoid cuts or injuries that can lead to infection, regular nail care is still essential for hygiene and overall skin health. Trimming nails carefully and keeping them clean is necessary. C) Rub skin dry - Rubbing the skin dry vigorously can further irritate and damage the skin, especially in individuals with compromised skin integrity. It's recommended to pat the skin gently to dry to avoid friction and trauma. D) Keep the neck in midline - While proper positioning is crucial for clients with certain medical conditions, maintaining the neck in midline does not directly address the issue of impaired skin integrity. This instruction is not as relevant to preventing skin breakdown. Educational context: Understanding the specific needs of clients with Hodgkin's disease is essential for nurses to provide comprehensive care. Educating clients on proper skin care practices can help prevent complications and promote overall well-being. By choosing the right interventions, nurses can enhance the quality of life for individuals undergoing treatment for Hodgkin's disease.

Correct Answer: C

Rationale: The correct answer is C) Place the client in high Fowler's position. Placing the client in high Fowler's position, with the head of the bed elevated at 90 degrees, helps to reduce pressure on the trachea caused by enlarged cervical lymph nodes in Hodgkin's lymphoma. This position also promotes increased lung expansion and improved air exchange by allowing the diaphragm to descend more freely, thereby enhancing respiratory function. Option A) Encouraging the use of incentive spirometry is a beneficial intervention for promoting deep breathing exercises and improving lung ventilation, but it does not directly address the issue of tracheal pressure caused by enlarged lymph nodes. Option B) Monitoring pulse oximetry and maintaining oxygen saturation at 90% or greater is important for assessing oxygenation status but does not directly alleviate tracheal pressure or improve lung expansion. Option D) Keeping the environment quiet and free of distraction is essential for promoting a restful and healing environment for the client but does not address the physiological need for improved respiratory function in this situation. Educationally, understanding the rationale behind positioning in high Fowler's is crucial for nurses caring for clients with respiratory issues like Hodgkin's lymphoma. It helps students grasp the importance of proper positioning in enhancing respiratory mechanics and ensuring adequate oxygenation for clients with compromised airways. This case underscores the significance of evidence-based nursing interventions in promoting optimal patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) Epstein-Barr virus. This virus is responsible for causing mononucleosis, also known as the "kissing disease." Mononucleosis is characterized by symptoms such as fever, sore throat, swollen lymph nodes, and fatigue. The Epstein-Barr virus is commonly spread through saliva, hence its association with kissing. Option A) Elephantiasis is caused by parasitic worms transmitted through mosquito bites and leads to severe swelling of body parts, not related to mononucleosis. Option B) Reed-Sternberg cells are characteristic of Hodgkin's lymphoma, a type of lymphoma, not mononucleosis. Option C) Lymphogranulomatosis is an outdated term for Hodgkin's lymphoma. This term is no longer commonly used in medical practice. Understanding the etiology of infections such as mononucleosis is crucial for healthcare professionals, especially nurses who may encounter and care for patients with these conditions. Knowing the correct causative agent helps in appropriate diagnosis, treatment, and patient education. Additionally, understanding the differences between similar-sounding conditions like mononucleosis and Hodgkin's lymphoma is essential for accurate clinical assessment and management.