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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the

patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.

For example:

Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.

Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.

Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.

Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:

Hives: No hives or rashes on the skin are normal.
Vomiting: No vomiting or nausea are normal.
Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).

A. Chicken, carrots, and fresh grapefruit salad. B. Salmon, turnip greens, brown rice, and an orange. C. Green salad, ground beef patty, corn, and applesauce. D. Plain omelet, bacon, toast with butter, and strawberries.

Correct Answer is B

Explanation

This meal selection best demonstrates a client with osteoporosis understands dietary recommendations because it provides adequate amounts of calcium, vitamin D, and protein, which are essential nutrients for bone health.

Choice A is wrong because chicken, carrots, and fresh grapefruit salad do not provide enough calcium or vitamin D for a person with osteoporosis.

Calcium is mainly found in dairy products, leafy green vegetables, and fish with bones. Vitamin D is mainly found in fatty fish, egg yolks, and fortified foods.

Choice C is wrong because green salad, ground beef patty, corn, and applesauce do not provide enough calcium or vitamin D for a person with osteoporosis.

Green salad may contain some calcium depending on the type of greens, but it is not a rich source.

Ground beef patty and corn are low in calcium and vitamin

D. Applesauce does not contain any calcium or vitamin

D. Choice D is wrong because plain omelet, bacon, toast with butter, and strawberries do not provide enough calcium or vitamin D for a person with osteoporosis.

Plain omelet and bacon are high in protein but low in calcium and vitamin

Toast with butter may contain some vitamin D if the bread or butter are fortified, but it is not a rich source.

Strawberries do not contain any calcium or vitamin

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Which nursing diagnosis takes priority for a client who is receiving chemotherapy treatment for cancer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of these assessment findings should a nurse record as subjective?

Correct Answer is B

Explanation

Which meal selection best demonstrates a client with osteoporosis understands dietary recommendations?

Correct Answer is B

Explanation

Which client has the greatest need for special mouth care?

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A community health nurse is teaching a group of older adults about risk factors for a hip fracture. What statements indicate a correct understanding of these risk factors? Select all that apply.

A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

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