Question

A client is admitted with polycythemia vera. Which would the nurse recommend including in the plan of care for this client? A. Assessing the client for signs of hypokalemia B. Preparing for administration of iron C. Monitoring the client for stroke symptoms D. Restricting fluids to prevent excess fluid volume

Short answer

Answer: Monitoring the client for stroke symptoms.

Step-by-step solution

Understanding polycythemia vera

Polycythemia vera is a rare blood disorder characterized by the overproduction of red blood cells, which can lead to an increased risk of blood clot formation. The blood becomes thicker, making it harder for the heart to pump it through the body. This can result in complications such as strokes and heart attacks.

Analyzing Option A

Option A suggests assessing the client for signs of hypokalemia. Hypokalemia is a condition characterized by low potassium levels in the blood. Although monitoring electrolyte levels can be important in patients with blood disorders, it is not specifically related to polycythemia vera and its complications.

Analyzing Option B

Option B suggests preparing for administration of iron. Iron is necessary for the production of red blood cells; however, in polycythemia vera, the body is already overproducing red blood cells. Therefore, administrating iron would not be an appropriate plan of care for the patient.

Analyzing Option C

Option C suggests monitoring the client for stroke symptoms. Due to the increased risk of blood clots and thicker blood caused by polycythemia vera, the risk of stroke is heightened. Monitoring for stroke symptoms would be an important part of nursing care for a client with this condition.

Analyzing Option D

Option D suggests restricting fluids to prevent excess fluid volume. While managing fluid balance is important, it is not the primary concern for a client with polycythemia vera. In fact, adequate hydration can help prevent blood from becoming too thick and reduce the risk of complications.

Choosing the Correct Option

Based on the analysis of each option, it becomes clear that monitoring the client for stroke symptoms (Option C) is the most appropriate nursing care recommendation for a client with polycythemia vera.

Key concepts

Blood Disorders

Blood disorders refer to conditions that affect the components of the blood, including red blood cells, white blood cells, platelets, plasma, and clotting factors. These disorders can disrupt normal blood function, leading to health issues.

Polycythemia vera is a prime example of a blood disorder. It is characterized by the excessive production of red blood cells. This results in increased blood viscosity, making it difficult for the heart to pump blood throughout the body efficiently.

The thickening of the blood in polycythemia vera can lead to serious complications. These include an elevated risk of blood clots and cardiovascular events like strokes and heart attacks. Managing blood disorders requires a careful approach to address these risks and maintain proper blood circulation.

• Identifying the specific blood disorder
• Monitoring blood levels and symptoms
• Implementing strategies to manage clotting risks

These steps are crucial in providing effective care for individuals with blood disorders like polycythemia vera.

Stroke Prevention

Stroke prevention is a critical component of managing polycythemia vera, as this condition increases the risk of stroke due to thick blood and potential clot formation. Effective stroke prevention strategies aim to reduce these risks and protect patients.

Here are key strategies for stroke prevention in polycythemia vera:

• Regular monitoring for signs of stroke, such as sudden numbness, confusion, or difficulty speaking
• Encouraging adequate hydration to maintain blood viscosity at safer levels
• Employing medical therapies to reduce red blood cell count and prevent clot formation
• Promoting a healthy lifestyle, including a balanced diet and regular exercise

Through these measures, patients can significantly reduce their risk of stroke and other complications associated with polycythemia vera.

Nursing Care

Nursing care plays an essential role in the management of polycythemia vera. Nurses are at the frontline of observing and responding to patients' needs, making their role critical in preventing complications.

Nursing interventions for polycythemia vera may include:

• Education on disease management and complication symptoms
• Monitoring vital signs and neurological status for indications of stroke
• Encouraging fluid intake to help manage blood thickness
• Assisting with planning and adhering to treatment regimens

Nurses also provide emotional and psychological support to patients and their families. This holistic approach to care ensures that patients with polycythemia vera receive comprehensive management, aiding in their overall well-being and reducing the risk of severe outcomes.