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 D

Explanation

Choice A reason: Aspirin can irritate the stomach lining and increase acid reﬂux, worsening GERD symptoms. It is generally not recommended without consulting a healthcare provider.
Choice B reason : Mercury content in seafood is not directly linked to GERD. This statement is misleading and does not address known risk factors for GERD.
Choice C reason : Lying down after eating can indeed increase the onset of GERD as it allows stomach contents to ﬂow back into the esophagus more easily.
Choice D reason : Alcohol and caﬀeine can relax the lower esophageal sphincter, allowing stomach acid to rise into the esophagus and worsen GERD symptoms. Therefore, it is advisable to avoid or reduce their intake.

A. Consume only vegetable proteins B. Limit his ﬂuid intake to 1500 mL or less per day C. Avoid taking drugs that may be nephrotoxic D. Self-catheterize for residual urine at least once a week

Correct Answer is C

Explanation

Choice A reason (acute renal failure): Patients recovering from acute renal failure are not typically restricted to only vegetable proteins. Protein needs can vary based on the individual's condition and treatment plan.

Choice B reason (acute renal failure): Fluid intake recommendations for patients recovering from acute renal failure depend on their current kidney function and ﬂuid balance status. A blanket restriction to 1500 mL or less per day may not be appropriate for all patients.

Choice C reason (acute renal failure): Avoiding nephrotoxic drugs is crucial for patients recovering from acute renal failure to prevent further kidney damage.

Choice D reason (acute renal failure): Self-catheterization for residual urine is not a standard recommendation for all patients recovering from acute renal failure. This would be specific to patients with urinary retention issues.

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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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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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