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.
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Correct Answer is B
Explanation
A. WBCs: White blood cell counts may vary in multiple myeloma, but they are not typically increased; in fact, WBC counts can be low due to bone marrow crowding.
B. Calcium: Multiple myeloma often causes hypercalcemia because of increased bone breakdown, leading to the release of calcium into the bloodstream.
C. Absolute neutrophil count: The absolute neutrophil count may actually decrease as a result of bone marrow dysfunction, not increase.
D. Platelets: Platelet counts are often decreased in multiple myeloma due to bone marrow involvement, not increased.
Correct Answer is C
Explanation
A. Folate: Folate is important for red blood cell production but does not address the Vitamin B12 deficiency seen in pernicious anemia.
B. Vitamin C: Vitamin C does not impact pernicious anemia as it is not involved in Vitamin B12 absorption.
C. Vitamin B12: Pernicious anemia occurs due to a lack of intrinsic factor, which is necessary for Vitamin B12 absorption. After a total gastrectomy, intrinsic factor is no longer produced, requiring Vitamin B12 supplementation.
D. Iron: Iron deficiency anemia is different from pernicious anemia, which specifically requires Vitamin B12 supplementation.