Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma?
Monitor fluid intake and output.
Limit weight bearing and ambulation.
Assess lymph nodes for enlargement.
Administer calcium supplements.
The Correct Answer is A
A. Monitor fluid intake and output. Monitoring fluid intake and output is essential in patients with multiple myeloma to assess for signs of dehydration or fluid overload, which can occur due to renal complications.
B. Limit weight bearing and ambulation. Limiting weight bearing and ambulation is not a
standard intervention for multiple myeloma unless there are specific complications such as bone fractures.
C. Assess lymph nodes for enlargement. Multiple myeloma primarily affects the bone marrow and plasma cells, not the lymph nodes.
D. Administer calcium supplements. While calcium supplementation may be necessary in some cases of multiple myeloma, it is not a priority action upon admission without further assessment.
Nursing Test Bank
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Related Questions
Correct Answer is B
Explanation
A. Tamoxifen: Tamoxifen is primarily used in the treatment of breast cancer, not prostate cancer.
B. Leuprolide: Leuprolide is a gonadotropin-releasing hormone (GnRH) agonist commonly used in the treatment of advanced prostate cancer to reduce testosterone levels, slowing the growth of cancer cells.
C. Cyclophosphamide: Cyclophosphamide is a chemotherapy drug used to treat various types of cancer but is not commonly used specifically for prostate cancer.
D. Finasteride: Finasteride is a 5-alpha-reductase inhibitor used to treat benign prostatic hyperplasia (BPH) and male pattern baldness but is not typically used in the treatment of advanced prostate cancer.
Correct Answer is A
Explanation
A. Given the low hemoglobin level and weight, the patient is likely experiencing fatigue due to decreased oxygen-carrying capacity of the blood, leading to activity intolerance.
B. While weight loss may contribute to body image disturbance, it is not the primary concern for a patient with iron-deficiency anemia and low hemoglobin levels.
C. Anxiety related to the hospital environment may be present, but it is not the most appropriate nursing diagnosis based on the patient's clinical presentation and laboratory findings.
D. Impaired tissue integrity related to immobility is not the most appropriate nursing diagnosis for a patient with iron-deficiency anemia. This diagnosis is more commonly associated with pressure ulcers or skin breakdown in patients who are immobile for extended periods, which is not described in this scenario.
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