Which of the following nursing diagnoses (nursing problem) would be of highest priority for the patient hospitalized for a bone marrow transplant to treat relapse of acute myelocytic leukemia?

Disturbed body image

Anxiety

Ineﬀective protection

Imbalanced nutrition: less than body requirements

Answer and Explanation

The Correct Answer is C

Choice A reason: While disturbed body image is a concern, it is not the highest priority for a patient undergoing a bone marrow transplant.

Choice B reason: Anxiety is important to address but does not take precedence over physical health concerns in the immediate post-transplant period.

Choice C reason: Ineﬀective protection is the highest priority because patients undergoing bone marrow transplants have compromised immune systems and are at high risk for infection.

Choice D reason: Imbalanced nutrition is a concern but is secondary to the risk of infection in the immediate care of a patient post bone marrow transplant.

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Correct Answer is A

Explanation

Choice A reason: A healthy stoma should be beefy red and moist, indicating good blood supply and hydration.

Choice B reason: A dusky maroon color could indicate compromised blood supply or ischemia.

Choice C reason: A pale and pink stoma may suggest anemia or reduced blood ﬂow.

Choice D reason: A stoma that is pink and dry could be dehydrated, which is not ideal.

A. Hypertension B. History of sickle cell disease C. Parent who has cardiovascular disease D. Client's age

Correct Answer is A

Explanation

Choice A reason: Hypertension is a well-known modifiable risk factor for stroke. Controlling blood pressure can significantly reduce the risk of having a stroke.
Choice B reason: A history of sickle cell disease is a genetic condition and is not considered a modifiable risk factor.
Choice C reason: Having a parent with cardiovascular disease is a non-modifiable risk factor as it is related to genetics.
Choice D reason: Age is a non-modifiable risk factor for stroke. The risk of stroke increases with age.

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Which of the following nursing diagnoses (nursing problem) would be of highest priority for the patient hospitalized for a bone marrow transplant to treat relapse of acute myelocytic leukemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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