The nurse admits an older adult patient to the emergency room ...

[RODY.ELKHALIL]

The nurse admits an older adult patient to the emergency room with reports of shortness of breath on exertion and a productive cough. The nurse reviews the patient's current medications and the patient says, I take one pink pill every morning.
 
   The nurse asks the name of the drug and the patient says she doesn't know. The patient cannot supply the name of the drug or the purpose in taking it either. This happens with four other medications the patient says she takes. What is an appropriate nursing diagnosis for this patient? A) Acute confusion
  B) Risk-prone health behavior
  C) Ineffective health maintenance
  D) Noncompliance

Question 2

A patient with rhabdomyosarcoma has been admitted for chemotherapy with vincristine. While preparing a plan of care for this patient, what would be an appropriate nursing diagnosis?
 
  A) Altered body image due to severe fluid retention
  B) Risk for bleeding due to possible hemorrhagic cystitis
  C) Risk for injury related to muscle wasting and weight loss
  D) Risk of infection related to possible nosocomial infection

[Awesome]

Answer to Question 1

C
Feedback:
This patient is demonstrating ineffective health maintenance because knowledge of what medications are being taken and why they are being taken is essential to her health. Patients should be instructed to carry an up-to-date list of current medications to share with all health care providers. She is taking her medication as ordered according to what she said so that would eliminate risk-prone health behaviors and noncompliance. There is no indication the patient is confused.

Answer to Question 2

C
Feedback:
Adverse effects of vincristine include ataxia, cranial nerve manifestations, neuritic pain, muscle wasting, constipation, leukopenia, weight loss, loss of hair, and death. As a result, the risk for injury due to weakness and falls is a significant concept. Risk for bleeding and severe fluid retention is unlikely with this drug. The risk of infection is related to bone marrow suppression, not a possible nosocomial infection. The patient is more at risk for a nosocomial infection because of the bone marrow suppression.