The client is prescribed collagenase (Xiaflex) for Dupuytren ...

[Mimi]

The client is prescribed collagenase (Xiaflex) for Dupuytren contracture. When developing this client's care plan, which nursing diagnoses will the nurse include?
 
  Standard Text: Select all that apply.
  1. Body Image, Disturbed
  2. Fatigue
  3. Pain, Chronic
  4. Falls, Risk for
  5. Tissue Perfusion: Peripheral, Risk for Ineffective

Question 2

The mother of a school-age client tells the school nurse, My son is so hyperactive. I can't see any harm in putting him on medication, especially since the stimulants have so few side effects. Which response by the nurse is the most appropriate?
 
  1. Stimulants can cause the side effect of excessive excitation.
  2. Have you made an appointment for your son to see the health care provider?
  3. Stimulants can be helpful in hyperactivity disorders.
  4. What actions lead you to think your son is hyperactive?

[bobsmith]

Answer to Question 1

Correct Answer: 1,5
Rationale 1: Dupuytren contracture causes malformation of the hand, which may result in disturbance of body image.
Rationale 2: Dupuytren contracture does not result in fatigue.
Rationale 3: Dupuytren contracture is generally not painful. Acute pain may occur with treatment.
Rationale 4: There is no risk for falls associated with Dupuytren contracture.
Rationale 5: A possible adverse effect of injection of collagenase is swelling of the affected hand, which could compromise tissue perfusion.
Global Rationale: Dupuytren contracture causes malformation of the hand, which may result in disturbance of body image. A possible adverse effect of injection of collagenase is swelling of the affected hand, which could compromise tissue perfusion. Dupuytren contracture does not result in fatigue. Dupuytren contracture is generally not painful. Acute pain may occur with treatment. There is no risk for falls associated with Dupuytren contracture.

Answer to Question 2

Correct Answer: 1
Rationale 1: A side effect of stimulants is excessive excitation.
Rationale 2: The misunderstanding is regarding whether stimulants have side effects, not obtaining an appointment with the health care provider.
Rationale 3: The mother already perceives that stimulants would help her son's behavior.
Rationale 4: In order to be prescribed a stimulant, the son would need to see a health care provider to determine symptoms of hyperactivity, but the misunderstanding here is regarding stimulants having side effects.
Global Rationale: The misunderstanding is regarding whether stimulants have side effects, not obtaining an appointment with the health care provider. A side effect of stimulants is excessive excitation. The mother already perceives that stimulants would help her son's behavior. In order to be prescribed a stimulant, the son would need to see a health care provider to determine symptoms of hyperactivity, but the misunderstanding here is regarding stimulants having side effects.

[Mimi]

Gracias!

[shailee]

Excellent