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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: An INR of 0.9 is within the normal range (0.8-1.2) and does not support the presence of bruising or bleeding disorders.
Choice B reason: A hematocrit level of 28% is below the normal range (36%-50% for women, 40%-54% for men), indicating anemia, but it does not directly explain bruising or petechiae.
Choice C reason: A WBC count of 4500 is within the normal range (4500-11000), suggesting that there is no active infection or leukocytosis that would explain the bruising.
Choice D reason: A platelet count of 60000 is below the normal range (150000-450000), which can lead to easy bruising and petechiae, supporting the nurse's observation.
Correct Answer is C
Explanation
Choice A reason: Nephrotoxicity causes intrinsic renal failure due to direct damage to the renal parenchyma, not pre-renal failure.
Choice B reason: Acute tubular necrosis is a type of intrinsic renal failure resulting from damage to the renal tubules, not pre-renal failure.
Choice C reason: Hypovolemia is a common cause of pre-renal failure due to decreased blood flow to the kidneys, leading to reduced urine output.
Choice D reason: Acute Glomerulonephritis is an intrinsic renal condition that affects the glomeruli, not a pre-renal cause.
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