Which nursing diagnosis takes priority for a client who is receiving chemotherapy treatment for cancer?

Situational low self-esteem related to job loss due to chemotherapy side effects.

Ineffective protection related to chemotherapy side effects.

Anticipatory grieving related to cancer diagnosis.

Fatigue related to cancer treatments.

Answer and Explanation

The Correct Answer is B

Ineffective protection related to chemotherapy side effects. This nursing diagnosis takes priority for a client who is receiving chemotherapy

treatment for cancer because chemotherapy can cause immunosuppression and increase the risk of infection, bleeding, and other complications.

According to the NANDA-I taxonomy, ineffective protection is defined as “decreased ability of an individual to guard the self from internal or external threats such as illness or injury” (NANDA International, 2018).

Choice A is wrong because situational low self-esteem related to job loss due to chemotherapy side effects is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can affect the client’s self-image and emotional well-being, it is not a life-threatening condition and can be addressed after ensuring the client’s safety and physiological needs.

Choice C is wrong because anticipatory grieving related to a cancer diagnosis is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although cancer can cause emotional distress and grief for the client and their family, it is not an immediate threat to the client’s health and can be managed with psychological support and counseling.

Choice D is wrong because fatigue related to cancer treatments is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can cause fatigue and weakness, it is not a critical condition and can be alleviated with rest, nutrition, and energy conservation strategies.

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Correct Answer is C

Explanation

I’d like to hear what you are thinking.” This response by the nurse would most likely prompt the client to elaborate on their concerns because it acknowledges the uncertainty of the situation and invites the client to share their feelings and thoughts.

It also shows empathy and respect for the client’s perspective.

Choice A is wrong because it may give false reassurance or minimize the client’s anxiety. Biopsies are not always negative and the nurse cannot predict the outcome.

Choice B is wrong because it may imply that the nurse is avoiding the question or shifting the responsibility to the health care provider.

It also does not address the client’s emotional state or encourage communication.

Choice D is wrong because it may dismiss the client’s fears or imply that they are irrational. It also does not explore the client’s understanding of the procedure or the possible results.

A uterine biopsy is a procedure that involves removing a small piece of tissue from the lining of the uterus (endometrium) for examination under a microscope. It is usually done to diagnose abnormal bleeding, infections, or cancer. The normal range of endometrial thickness varies depending on the menstrual cycle, age, and hormonal status of the woman.

A. Use exaggerated mouth and hand movements when speaking. B. Face the client while speaking and ask them to verify understanding. C. Stand in front of a light when speaking to the client and touch them to be sure they know where you are. D. Obtain an interpreter for sign language.

Correct Answer is B

Explanation

Face the client while speaking and ask them to verify understanding. This intervention would help the client to read the nurse’s lips and confirm the message.

It would also show respect and empathy for the client’s condition.

Choice A is wrong because using exaggerated mouth and hand movements when speaking can be distracting and insulting to the client.

It can also distort the words and make them harder to understand.

Choice C is wrong because standing in front of a light when speaking to the client can create glare and make it difficult for the client to see the nurse’s face.

Touching the client to be sure they know where you are can be startling and unnecessary if the client is not visually impaired.

Choice D is wrong because obtaining an interpreter for sign language is inappropriate unless the client knows sign language.

Not all hearing-impaired clients use sign language, and some may prefer other methods of communication.

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Which nursing diagnosis takes priority for a client who is receiving chemotherapy treatment for cancer?

Nursing Test Bank

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Correct Answer is C

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Correct Answer is B

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