A patient with rhabdomyosarcoma has been admitted for chemotherapy with vincristine. While preparing a plan of care for this patient, what would be an appropriate nursing diagnosis?
A) Altered body image due to severe fluid retention
B) Risk for bleeding due to possible hemorrhagic cystitis
C) Risk for injury related to muscle wasting and weight loss
D) Risk of infection related to possible nosocomial infection
C
Feedback:
Adverse effects of vincristine include ataxia, cranial nerve manifestations, neuritic pain, muscle wasting, constipation, leukopenia, weight loss, loss of hair, and death. As a result, the risk for injury due to weakness and falls is a significant concept. Risk for bleeding and severe fluid retention is unlikely with this drug. The risk of infection is related to bone marrow suppression, not a possible nosocomial infection. The patient is more at risk for a nosocomial infection because of the bone marrow suppression.
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