Which nursing diagnosis takes priority for a client who is receiving chemotherapy treatment for cancer?
Situational low self-esteem related to job loss due to chemotherapy side effects.
Ineffective protection related to chemotherapy side effects.
Anticipatory grieving related to cancer diagnosis.
Fatigue related to cancer treatments.
The Correct Answer is B
Ineffective protection related to chemotherapy side effects. This nursing diagnosis takes priority for a client who is receiving chemotherapy
treatment for cancer because chemotherapy can cause immunosuppression and increase the risk of infection, bleeding, and other complications.
According to the NANDA-I taxonomy, ineffective protection is defined as “decreased ability of an individual to guard the self from internal or external threats such as illness or injury” (NANDA International, 2018).
Choice A is wrong because situational low self-esteem related to job loss due to chemotherapy side effects is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can affect the client’s self-image and emotional well-being, it is not a life-threatening condition and can be addressed after ensuring the client’s safety and physiological needs.
Choice C is wrong because anticipatory grieving related to a cancer diagnosis is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although cancer can cause emotional distress and grief for the client and their family, it is not an immediate threat to the client’s health and can be managed with psychological support and counseling.
Choice D is wrong because fatigue related to cancer treatments is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can cause fatigue and weakness, it is not a critical condition and can be alleviated with rest, nutrition, and energy conservation strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Use a fresh washcloth when cleaning each eye. This is because using the same washcloth for both eyes can transfer microorganisms from one eye to the other and cause cross-infection.
The other choices are wrong because:
Choice A is wrong because wiping from the outer part of the eye toward the inner portion can introduce microorganisms into the tear ducts and cause infection.
Choice B is wrong because rinsing the washcloth before washing the second eye does not eliminate all the microorganisms that might be on the cloth.
Choice C is wrong because asking the client to roll the eyes upward does not prevent spreading organisms from one eye to the other when bathing a client.
Normal ranges for eye hygiene are to use a clean washcloth or cotton ball for each eye, wipe from the inner to the outer canthus, and use warm water or saline solution.
Correct Answer is D
Explanation
Independent. An independent nursing intervention is an action that a nurse can perform by themselves, without any management from a doctor or another discipline.
Taking the client’s temperature again is an example of an independent nursing intervention because it does not require a physician’s order or collaboration with other health care professionals.
Choice A is wrong because an interdependent nursing intervention is an action that requires collaboration or consultation with other health care professionals.
Taking the client’s temperature again does not involve working with other disciplines.
Choice B is wrong because a dependent nursing intervention is an action that requires an order from a physician or another health care provider.
Taking the client’s temperature again does not require a physician’s order.
Choice C is wrong because a collaborative nursing intervention is an action that involves working with other health care professionals to provide patient care.
Taking the client’s temperature again does not require collaboration with other disciplines.
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