Author Question: What nursing diagnosis is a priority for the 87-year-old woman, who has stomatitis secondary to the ... (Read 51 times)

captainjonesify · **on:** Jul 23, 2018

What nursing diagnosis is a priority for the 87-year-old woman, who has stomatitis secondary to the administration of methotrexate? (Select all that apply.)

A) Impaired skin integrity
B) Risk for infection
C) Imbalanced nutrition
D) Risk for bleeding
E) Hopelessness

Question 2

The nurse is caring for a patient who takes ramipril (Altace) to treat hypertension. What would be an appropriate nursing diagnosis to include in this patient's care plan?

A) Ineffective tissue perfusion related to changes in cardiac output
B) Acute pain related to skin effects and headache
C) Altered gas exchange related to unrelenting cough
D) Impaired body image

pratush dev · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

A, B, C, D
Feedback:
Because of the common adverse effects of severe bone marrow suppression, fatigue, malaise, rashes, alopecia, ulcerative stomatitis, hepatic toxicity, interstitial pneumonitis, chills, fever, and anaphylaxis, priority nursing diagnosis would include impaired skin integrity related to rash, risk for infection, and risk for bleeding related to severe bone marrow suppression. Because the patient has stomatitis, there is a risk for imbalanced nutrition less than body requirements because eating is uncomfortable and not feeling well will also reduce her appetite. Although fear and anxiety are common with any cancer diagnosis, hopelessness is usually not as common unless the patient receives a terminal diagnosis and, even then, many patients are able to remain hopeful.

Answer to Question 2

A
Feedback:
Nursing diagnoses related to drug therapy might include ineffective tissue perfusion (total body) related to changes in cardiac output because ramipril is associated with adverse effects such as reflex tachycardia, chest pain, angina, heart failure, and cardiac arrhythmias. Although dermatitis and rash may occur, headaches are not an associated adverse effect of this drug. Benazepril, enalapril, and fosinopril can cause an unrelenting cough but ramipril is not associated with this adverse effect. Impaired body image would not be associated with this drug.