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Which nursing problem has the highest priority when planning care for a client with osteomalacia?

Altered tissue perfusion.

Sleep pattern disturbance.

Risk for injury.

Risk of infection.

Answer and Explanation

The Correct Answer is C

Choice A reason: Altered tissue perfusion is important but not the primary concern in osteomalacia.

Choice B reason: Sleep pattern disturbance may occur but is not the highest priority.

Choice C reason:

The correct answer is c) because clients with osteomalacia have weakened bones and are at high risk for fractures, making injury prevention the highest priority.

Choice D reason: Risk of infection is important but not the primary concern in osteomalacia.

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Correct Answer is C

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason:

The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

A. Washes the radiation site with antibacterial soap and water. B. Dries the area with patting motions after taking a shower. C. Applies prescribed lotions to the radiation site. D. Wears clothing to cover the radiation site.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because using antibacterial soap can be too harsh and irritating for the skin that is undergoing radiation treatment. Gentle cleansing with mild soap is recommended to avoid skin irritation.

Choice B reason: Drying the area with patting motions is appropriate as it helps prevent further irritation to the sensitive skin.

Choice C reason: Applying prescribed lotions is recommended to keep the skin moisturized and help with any radiation-induced dryness or irritation.

Choice D reason: Wearing clothing to cover the radiation site can protect the area from sun exposure and further irritation, which is appropriate care for the skin.

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Which nursing problem has the highest priority when planning care for a client with osteomalacia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is C

Explanation

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

Correct Answer is A

Explanation

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