Nokea
A 70-year-old male with the diagnosis of claudication has been hospitalized for an evaluation of his increasingly impaired mobility and complaints of pain. The client tells the nurse that he can no longer walk a block without having severe pain in his left calf and foot. Based on these data, which nursing diagnosis would be most appropriate for this client?
- A. Activity intolerance related to decreased blood supply and pain
- B. Self-care deficit related to increased leg pain
- C. Ineffective coping related to chronic pain
- D. Impaired skin integrity related to poor circulation
Correct Answer: A
Rationale: Activity intolerance due to decreased blood supply and pain is the most appropriate nursing diagnosis, as claudication (pain during walking) directly results from inadequate arterial blood flow, limiting mobility. The other diagnoses may apply but are less specific to the described symptoms.
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A female client diagnosed with lung cancer is to have a left lower lobectomy. Which of the following increase the client's risk of developing postoperative pulmonary complications?
- A. Height is 5 feet, 7 inches and weight is 110 lb.
- B. The client tends to keep her real feelings to herself.
- C. 8.88 stimulates and can climb one flight of stairs without dyspnea.
- D. The client is 58 years of age.
Correct Answer: A
Rationale: Low body weight (5'7€, 110 lb) indicates malnutrition, increasing the risk of postoperative pulmonary complications due to weakened respiratory muscles. Emotional suppression, good exercise tolerance, and age 58 are less directly related.
Cushing's disease is manifested by the excessive secretion of corticosteroids. The hormones involved are:
- A. Glucocorticoids and aldosterone.
- B. Adrenocorticotropic hormone (ACTH).
- C. Glucocorticoids, aldosterone, and androgens.
- D. Catecholamines.
Correct Answer: C
Rationale: Cushing's disease involves excess glucocorticoids, aldosterone, and androgens due to adrenal hypersecretion.
Which of the following expected outcomes would be appropriate for a client with viral hepatitis? The client will:
- A. Demonstrate a decrease in fluid retention related to ascites.
- B. Verbalize the importance of reporting bleeding gums or bloody stools.
- C. Limit use of alcohol to two to three drinks per week.
- D. Restrict activity to within the home to prevent disease transmission.
Correct Answer: B
Rationale: Reporting bleeding (B) indicates awareness of complications like coagulopathy. Ascites (A) is more relevant to cirrhosis. Alcohol (C) should be avoided entirely. Restricting activity to home (D) is unnecessary for hepatitis B or C.
While talking to her husband, who is caring for their children, a 52-year-old client slams the phone down. She begins to cry and states that she is feeling guilty for being hospitalized. Which of the following interventions will best support the client emotionally?
- A. Call the physician and ask for a psychiatry consultation.
- B. Call the physician and request an antidepressant medication.
- C. Sit with the client and help her acknowledge and discuss her feelings.
- D. Sit with the client and encourage her to see the good side of the situation.
Correct Answer: C
Rationale: Sitting with the client and helping her discuss her feelings validates her emotions and supports her in processing guilt, providing emotional relief.
A 65-year-old male has hearing loss and a sensation of fullness in both ears. The nurse examines his ears with the understanding of the cause of hearing loss in older adults is related to:
- A. Accumulation of cerumen in the external canal.
- B. Accumulation of cerumen in the internal canal.
- C. External otitis.
- D. Exostosis.
Correct Answer: A
Rationale: Accumulation of cerumen in the external canal is a common cause of conductive hearing loss in older adults, leading to a sensation of fullness and reduced hearing.