A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care?
Hygiene self-care deficit related to uremic frost.
High risk for infection related to subclavian catheter.
High risk for injury related to ambulation.
Knowledge deficit related to high-protein diet.
The Correct Answer is A
Choice A: Uremic frost is a symptom of advanced kidney disease and can result in deposits of urea crystals on the skin. This can cause itching and discomfort, making it difficult for the client to maintain good hygiene and self-care. Therefore, addressing hygiene self-care deficit related to uremic frost is a priority in the plan of care for a client with renal osteodystrophy.
Choice B: This is not directly related to renal osteodystrophy and is more related to the presence of a catheter.
Choice C: This is not typically associated with renal osteodystrophy unless there are specific mobility issues related to bone problems.
Choice D: This may be relevant for clients with CKD, but it is not specific to renal osteodystrophy, which primarily involves bone mineral imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.
Choice B: Chilling the enema solution is not recommended because it can cause cramping, discomfort, and vasoconstriction, which may interfere with the client's fever assessment.
Choice C: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.
Choice D: Inserting the lubricated tip of tubing 3 to 4 inches into the rectum prevents injury to the rectal mucosa and ensures proper placement of the tubing.
Choice E: Clamping the enema administration tubing after filling the enema bag is unnecessary and may cause air to enter the tubing, which can increase the risk of abdominal distension and gas pain.
Correct Answer is B
Explanation
Choice A: A platelet count of 135,000/mm3 is slightly below the lower end of the normal range, but it may not be considered critically low. It is not the highest priority finding among the choices provided.
Choice B: A blood urea nitrogen (BUN) level of 75 mg/dL is significantly elevated and outside the normal range. Elevated BUN can indicate kidney dysfunction or dehydration and should be reported promptly.
Choice C: Decreased deep tendon reflexes may be related to various factors, including medication effects, and may not be considered the highest priority finding unless it is associated with other concerning symptoms.
Choice D: Periodic nausea and vomiting can be common side effects of chemotherapy, but they may not be considered the highest priority finding unless they are severe, persistent, or associated with signs of dehydration or electrolyte imbalances.
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