A nurse is caring for a client who is at risk for erythema during ...

[Awilson837]

A nurse is caring for a client who is at risk for erythema during antineoplastic drug therapy. The nurse identifies a nursing diagnosis of Impaired Tissue Integrity. Which of the following would be appropriate to suggest?
 
  A) Scrub and clean skin often.
  B) Wear loose protective clothing.
  C) Ensure adequate sunlight.
  D) Have frequent baths.

Question 2

Which of the following would the nurse most likely identify as a nursing diagnosis for a client who is receiving an immunization?
 
  A) Risk for Infection
  B) Acute Pain
  C) Hyperthermia
  D) Ineffective Coping

[briezy]

Answer to Question 1

Ans: B
Feedback:
The nurse should suggest to the client to wear loose protective clothing and to watch areas of skinfolds for breakdown. The nurse should not suggest that the client scrub and clean the skin often, ensure adequate sunlight, or have frequent baths as these measures may aggravate the condition and cause further impairment to the tissue. The client is advised to avoid sunlight.

Answer to Question 2

Ans: B
Feedback:
The client who is receiving an immunization would most likely experience pain at the injection site; therefore, Acute Pain would be most appropriate. If the drug was not given, then the client would be at risk for infection. Although fever may occur, Hyperthermia as a nursing diagnosis would be inappropriate. Ineffective Coping would not be associated with immunologic agents.

[Awilson837]

TYSM

[JaynaD87]

Gracias!