what is the priority nursing diagnosis for a client with metastatic bone disease

ATI RN

Multi Dimensional Care | Final Exam

1. What is the priority nursing diagnosis for a client with metastatic bone disease?

A. Chronic pain
B. Impaired mobility
C. Risk for falls
D. Risk for infection

Correct answer: C

Rationale: The correct answer is 'Risk for falls.' In clients with metastatic bone disease, weakened bones can lead to an increased risk of falls, making it a priority nursing diagnosis. Chronic pain (choice A) may be present but addressing the risk for falls is more critical in this situation. While impaired mobility (choice B) can be a consequence of metastatic bone disease, preventing falls takes precedence. Risk for infection (choice D) is not the priority in this case, as falls pose a more immediate threat to the client's safety.

2. What evaluation indicates successful progress on the client goal of increasing daily physical activity?

A. The client reports decreased social interaction
B. The client reports more nonsteroidal anti-inflammatory drug (NSAID) use
C. The client reports a fall
D. The client reports less fatigue walking up stairs

Correct answer: D

Rationale: The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.

3. A client with chronic osteomyelitis is being discharged from the hospital. What is the nurse’s priority discharge intervention?

A. Teaching adherence to an exercise program
B. Teaching about a healthy dietary intake
C. Teaching adherence to the antibiotic regimen
D. Scheduling daily dressing changes

Correct answer: C

Rationale: The correct answer is C: Teaching adherence to the antibiotic regimen. In chronic osteomyelitis, the priority is to ensure proper treatment of the infection, which heavily relies on consistent adherence to the prescribed antibiotic regimen. This helps in eradicating the infectious organisms and preventing recurrence. Choices A, B, and D are important aspects of care but teaching adherence to the antibiotic regimen takes precedence as it directly impacts the successful management of chronic osteomyelitis.

4. What occurs during stage three of bone healing?

A. Consolidation
B. Callus formation
C. Granulation formation
D. Hematoma formation

Correct answer: B

Rationale: During stage three of bone healing, callus formation occurs. This process involves the formation of a soft callus made of collagen and cartilage, which bridges the gap between bone fragments. Choice A, consolidation, typically happens in later stages and involves the hardening of the callus into mature bone. Choices C and D are incorrect as granulation formation and hematoma formation occur in earlier stages of bone healing, specifically stages one and two, respectively.