Author Question: The nurse is caring for an older adolescent client diagnosed with malignant melanoma. Which nursing ... (Read 103 times)

newyorker26 · **on:** Jun 25, 2018

The nurse is caring for an older adolescent client diagnosed with malignant melanoma. Which nursing diagnoses would be appropriate when planning this client's care?

Select all that apply.
A) Impaired Skin Integrity
B) Risk for Compromised Human Dignity
C) Anxiety
D) Risk for Acute Confusion
E) Disturbed Body Image

Question 2

A resident in an assisted-living facility is restless most nights and sits in the lounge area reading. When questioned, the resident reports suffering from insomnia.

What should the nurse expect as an outcome if the resident continues with this pattern of sleep?
A) Safety issues with an unsupervised resident in the lounge area
B) Onset of cardiac dysfunction
C) Onset of new underdiagnosed health problems
D) The ability to function during the day may be hindered by these episodes.

234sdffa · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: A, C, E

Any client will likely experience anxiety and impaired skin integrity related to the diagnosis of skin cancer. The client will not likely have compromised human dignity or a risk for acute confusion. Disturbed body image could be an issue if the lesion is large.

Answer to Question 2

Answer: D

Insomnia is defined as an inability to fall asleep or stay asleep on most nights for over a month. The individual experiencing insomnia is at risk for daytime drowsiness and may experience problems with concentration and function. Insomnia is not a cause for liability; it is up to the nurse to make sure that hospitalized client are safe, but the client cannot be restricted from moving about. There is no evidence that insomnia leads to cardiac problems. There is no evidence that the resident client is demonstrating underlying problems.