A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care?
Hygiene self-care deficit related to uremic frost.
High risk for infection related to subclavian catheter.
High risk for injury related to ambulation.
Knowledge deficit related to high-protein diet.
The Correct Answer is A
Choice A: Uremic frost is a symptom of advanced kidney disease and can result in deposits of urea crystals on the skin. This can cause itching and discomfort, making it difficult for the client to maintain good hygiene and self-care. Therefore, addressing hygiene self-care deficit related to uremic frost is a priority in the plan of care for a client with renal osteodystrophy.
Choice B: This is not directly related to renal osteodystrophy and is more related to the presence of a catheter.
Choice C: This is not typically associated with renal osteodystrophy unless there are specific mobility issues related to bone problems.
Choice D: This may be relevant for clients with CKD, but it is not specific to renal osteodystrophy, which primarily involves bone mineral imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A: Closing the blinds to darken the room may not be the immediate priority during a seizure. Ensuring the safety and well-being of the child takes precedence.
Choice B: Asking the mother to release the child is an important action. It is essential to prevent any further physical restraint during a seizure, as it can cause harm to the child or the person attempting to restrain them.
Choice C: Monitoring the child's airway and tongue is crucial during a seizure to prevent any obstruction that could interfere with breathing. It is important to ensure the child does not choke on saliva or vomit.
Choice D: Administering an anticonvulsant medication may be necessary in certain situations, especially if the seizure persists or is prolonged. The healthcare provider's orders should be followed for the administration of appropriate medications
Choice E: Placing pillows inside the side rails is not a relevant intervention during a seizure. The focus should be on ensuring the child's safety, assessing their airway, and providing appropriate care during the seizure.
Correct Answer is B
Explanation
Choice A: A platelet count of 135,000/mm3 is slightly below the lower end of the normal range, but it may not be considered critically low. It is not the highest priority finding among the choices provided.
Choice B: A blood urea nitrogen (BUN) level of 75 mg/dL is significantly elevated and outside the normal range. Elevated BUN can indicate kidney dysfunction or dehydration and should be reported promptly.
Choice C: Decreased deep tendon reflexes may be related to various factors, including medication effects, and may not be considered the highest priority finding unless it is associated with other concerning symptoms.
Choice D: Periodic nausea and vomiting can be common side effects of chemotherapy, but they may not be considered the highest priority finding unless they are severe, persistent, or associated with signs of dehydration or electrolyte imbalances.
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