A child with leukemia is receiving methotrexate for therapy. Which nursing diagnosis should the nurse use to best guide this patient's care at this time?
A) Impaired oral mucous membrane related to effects of chemotherapy
B) Risk for impaired mobility related to depressant effects of methotrexate
C) Excess fluid volume related to effect of methotrexate on aldosterone secretion
D) Risk for self-directed violence related to effect of methotrexate on central nervous system
A
Feedback:
Mucositis or ulcers of the gum line and mucous membranes of the mouth is a frequent effect of antimetabolic drugs. This is the diagnosis that would have the highest priority for the patient's care at this time. Methotrexate does not impair mobility, impact aldosterone secretion, or cause adverse effects to the central nervous system.
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