The nurse is caring for a 16-year-old boy with acute myelogenous leukemia. He is having chemotherapy and has incomplete records for varicella zoster immunization. Which of the following will be the priority nursing diagnosis?
A) Pain related to adverse effects of treatment verbalized by child
B) Nausea related to side effects of chemotherapy verbalized by child
C) Constipation related to the use of opioid analgesics for pain
D) Risk for infection related to neutropenia and immunosuppression
D
Response:
The priority nursing diagnosis is risk for infection related to neutropenia and immunosuppression. The incomplete records for varicella zoster immunization can cause a problem since exposure to chickenpox could cause sepsis, so the nurse should contact the oncologist for approval to administer the vaccine. Certain vaccines are not administered when the child is immunosuppressed, so timing is crucial. Diagnoses for pain and nausea are valid for this child because he is undergoing chemotherapy, but they are not the priority. Likewise, the need for constipation management would not be necessary until opioid use begins.
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