Nokea
A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?
- A. Place the arm in the sling
- B. Apply cold soaks to the affected arm
- C. Introduce variations in styles of clothing
- D. Tie a tight bandage to the arm
Correct Answer: C
Rationale: Introducing variations in styles of clothing can help the client feel more comfortable and confident despite the abnormal enlargement of her arm due to lymphedema. By wearing different styles of clothing that accommodate the affected arm, the client can still express her personal style and feel good about her appearance. This approach can help improve the client's self-image and self-esteem, supporting her emotionally as she copes with the condition. Placing the arm in a sling, applying cold soaks, or tying a tight bandage are not appropriate suggestions for addressing the client's anxiety and self-image concerns in this situation.
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An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
- A. Potential for infection
- B. Self care deficit
- C. Alteration in infection
- D. Fluid volume excess
Correct Answer: A
Rationale: The decreased white blood cell count (WBC) in the blood tests indicates a potential for infection. White blood cells are crucial for fighting off infections in the body. A decrease in WBC count can result in an impaired immune response, making the individual more susceptible to infections. Therefore, the nurse should prioritize the nursing diagnosis of "Potential for infection" to address the heightened risk of infection in the adult with anemia. It is important to monitor for signs and symptoms of infection, provide appropriate hygiene measures, and implement interventions to prevent infections in this individual.
A 19-year-old student develops symptoms of respiratory alkalosis related to an anxiety attack. Which nursing intervention is appropriate?
- A. Make sure his oxygen is being administered as ordered.
- B. Have him breathe into a paper bag.
- C. Place him in a semi-fowler's position.
- D. Have him do coughing and deep breathing exercises.
Correct Answer: B
Rationale: The appropriate nursing intervention for a 19-year-old student experiencing symptoms of respiratory alkalosis related to an anxiety attack is to have him breathe into a paper bag. Breathing into a paper bag can help increase the level of carbon dioxide in the body, which can help correct respiratory alkalosis. This technique helps to rebalance the level of carbon dioxide in the blood and alleviate the symptoms of alkalosis caused by hyperventilation during the anxiety attack. It is important to monitor the student's condition and ensure that he is using the paper bag correctly to avoid any potential risks associated with this intervention. Additionally, providing reassurance and support during this episode can also be beneficial in helping the student to manage his anxiety and respiratory alkalosis.
A few hours before the patient was admitted at the hospital, he complained of fever, nausea and vomiting, and vague abdominal pain. The doctor examined the patient as a case of acute appendicitis and prepared for appendectomy. The nurse anticipates that this type of surgery is classified as:
- A. emergency
- B. urgent
- C. elective
- D. required
Correct Answer: A
Rationale: Appendectomy as a treatment for acute appendicitis is classified as an emergency surgery. Acute appendicitis is considered a medical emergency that requires prompt surgical intervention to prevent complications such as a ruptured appendix, which can lead to peritonitis, a life-threatening condition. In emergency situations, surgery must be done urgently to address the immediate threat to the patient's health. This is in contrast to elective surgeries, which are typically scheduled in advance and do not require immediate attention. In the case described, the patient's symptoms of fever, nausea, vomiting, and vague abdominal pain suggest an acute presentation that necessitates urgent surgical intervention, making it an emergency appendectomy.
A school nurse is conducting a class with adolescents on suicide. Which true statement about suicide should the nurse include in the teaching session?
- A. A sense of hopelessness and despair are a normal part of adolescence.
- B. Gay and lesbian adolescents are at a particularly high risk for suicide.
- C. Problem-solving skills are of limited value to the suicidal adolescent.
- D. Previous suicide attempts are not an indication of risk for completed suicides.
Correct Answer: B
Rationale: Gay and lesbian adolescents are at a particularly high risk for suicide. Research has shown that sexual minority youth, such as gay, lesbian, bisexual, and transgender adolescents, are at a higher risk for suicide due to the stress, discrimination, and lack of acceptance they may face. It is important for the school nurse to address the unique risk factors and challenges faced by LGBTQ+ adolescents when discussing suicide prevention in order to provide appropriate support and resources.
which of the following blood tests results is the most indicative of an improvement in rheumatic fever child?
- A. WBCS 11,000
- B. decrease ESR
- C. elevated ASOT
- D. hemoglobin 10 gm/dl.
Correct Answer: B
Rationale: Erythrocyte Sedimentation Rate (ESR) is a non-specific marker for inflammation and can be elevated in conditions like rheumatic fever. A decrease in ESR suggests a reduction in the inflammatory response in the body, indicating an improvement in the condition. While the other parameters (WBC count, ASOT, and hemoglobin level) may be affected in rheumatic fever, a decrease in ESR is a more direct indicator of improvement in the inflammatory process associated with the disease.