The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching?
Ineffective airway clearance related to swelling of the lymph nodes
Ineffective tissue perfusion related to vascular occlusion
Risk for injury related to compromised bone integrity
Risk for deficit fluid volume related to a bleeding disorder
The Correct Answer is C
A. Ineffective airway clearance related to swelling of the lymph nodes: Multiple myeloma primarily affects bone marrow and bones rather than lymph nodes, so this diagnosis is less relevant.
B. Ineffective tissue perfusion related to vascular occlusion: Vascular occlusion is not a common complication of multiple myeloma, although hyperviscosity can occur, especially in advanced stages. However, the primary concern is bone integrity.
C. Risk for injury related to compromised bone integrity: Multiple myeloma weakens bones due to the presence of osteolytic lesions, increasing the risk for fractures. Teaching the family about measures to prevent injury is crucial.
D. Risk for deficit fluid volume related to a bleeding disorder: Multiple myeloma does not usually cause a primary bleeding disorder that would result in fluid volume deficit. Bone fractures and hypercalcemia are more immediate concerns.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
A. Heat relaxes the muscles and distracts the patient from the pain. While warmth can provide comfort, the main goal is to improve circulation rather than distraction.
B. Sickle cell crisis pain can be exacerbated with shivering. Although shivering may be uncomfortable, it is not the primary reason for using heat during a sickle cell crisis.
C. Heat promotes proper formation of red blood cells (RBCs) and prevents sickling. Heat does not affect RBC formation or prevent sickling. The condition of sickling is due to genetic factors, not temperature.
D. Heat increases circulation by preventing vasoconstriction. In sickle cell crisis, warmth helps prevent vasoconstriction, which can reduce blood flow to areas already compromised by sickled cells. Preventing vasoconstriction may help alleviate pain and improve circulation.
Correct Answer is B
Explanation
A. Have the patient take a number and stay in the waiting area. Delaying care could lead to worsening of a potentially life-threatening bleeding episode. Hemophilia patients should be assessed promptly.
B. Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis. Hemophilia patients are at risk of internal bleeding, which may not always be visible externally. Rapid assessment is essential to prevent complications from internal bleeding.
C. Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room. X-rays may not immediately detect bleeding in soft tissues. The physician should evaluate the patient first.
D. Palpate the suspected area of bleeding for tenderness and edema. Palpating could worsen bleeding or cause pain, and the nurse should focus on ensuring the patient is seen promptly by the physician.