Assessment of a client receiving anticonvulsant therapy reveals the following: sore throat, chills, fever, gingival bleeding, and bruising. Which nursing diagnosis would the nurse most likely identify?
A) Risk for Impaired Skin Integrity
B) Impaired Oral Mucous Membranes
C) Risk for Injury
D) Risk for Infection
Ans: D
Feedback:
The assessment findings suggest pancytopenia, so Risk for Infection would be most likely. Risk for Impaired Skin Integrity would be appropriate if the client developed a rash. Impaired Oral Mucous Membranes would be appropriate if the client was exhibiting signs of gingival hyperplasia. Risk for Injury would be appropriate if the client was experiencing drowsiness, ataxia, and vision disturbances related to the drug therapy.
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