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A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?
- A. Anticipatory grieving
- B. Disturbed body image
- C. Impaired swallowing
- D. Chronic low self-esteem
Correct Answer: A
Rationale: Anticipatory grieving is an appropriate nursing diagnosis for a client diagnosed with gallbladder cancer due to the nature of the diagnosis and the symptoms experienced. Gallbladder cancer carries a poor prognosis and can have a significant impact on the client's emotional well-being. The client may experience feelings of sadness, fear, and loss related to the cancer diagnosis and its implications on their health and future. The presence of symptoms such as yellow skin, weight loss, fatigue, and epigastric pain can further contribute to the client's distress and feelings of grief. As the client navigates the challenges associated with the cancer diagnosis and treatment, providing emotional support and assistance in coping with their feelings of anticipatory grief is essential for holistic care.
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The LPN is caring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states, "I know I am not going to wake up after surgery." Which of the following actions should the nurse take?
- A. Reassure patient everything will be all right
- B. Explain national surgery death rate
- C. Inform the registered nurse
- D. Ask family to comfort the patient
Correct Answer: C
Rationale: The correct action for the LPN to take in this situation is to inform the registered nurse. The patient's statement indicates a high level of fear and anxiety about the surgery and their potential outcome. It is important to involve the registered nurse, who can provide further assessment, support, and interventions to address the patient's concerns appropriately. Simply reassuring the patient or providing statistics about national surgery death rates may not address the underlying fear and may require additional support and intervention. Asking the family to comfort the patient may not be the most appropriate immediate action as the patient's concerns are specific and may require professional support. Bringing the registered nurse into the situation allows for a comprehensive approach to addressing the patient's emotional needs before the surgery.
The Andrews family has been taking good care of their youngest, Archie, who was diagnosed with asthma. Which of the following statements indicate a need for further home care teaching?
- A. "He should increase his fluid intake regularly to thin secretions."
- B. "We'll make sure that he avoids exercise to prevent attacks."
- C. "He is to use his bronchodilator inhaler before the steroid inhaler."
- D. "We need to identify what things trigger his attacks." 50
Correct Answer: B
Rationale: It is important to note that exercise should not be completely avoided for a child with asthma. Regular physical activity is beneficial for overall health and can help improve lung function in asthmatic individuals. Supervised and controlled exercise under the guidance of healthcare providers can be safe for children with asthma. Avoiding exercise altogether can lead to deconditioning and other health issues. It is important to educate the family on the proper management of asthma during exercise, such as using a rescue inhaler before engaging in physical activity. Therefore, this statement indicates a need for further home care teaching.
A client has cancer that has me tastasized to her bones. She is complaining of increased thirst, polyuria and decreased muscle tone. Her lab values are: Na 139mEq/L, k 4 mEq/L, Cl 103 mEq/L, and Ca 8 mg/dl. What electrolyte imbalance is present?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hypercalcemia
- D. Hypochloremia
Correct Answer: C
Rationale: The patient's symptoms of increased thirst, polyuria, decreased muscle tone, and the lab value of high calcium (8 mg/dl) indicate hypercalcemia. Hypercalcemia is commonly seen in cancer patients due to cancer metastasis to the bones, leading to the release of calcium. The other electrolyte levels (sodium, potassium, and chloride) are within normal range, ruling out other electrolyte imbalances. Multiple myeloma is a common malignancy associated with bone metastases and hypercalcemia. Symptoms of hypercalcemia may include thirst, frequent urination, weakness, confusion, and muscle pain. Treatment of hypercalcemia may involve hydration, loop diuretics, bisphosphonates, and addressing the underlying cause.
Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The nurse explains that:
- A. Upper extremities are paralyzed
- B. Both lower and upper extremities are
- C. Lower extremities are paralyzed paralyzed
- D. One side of the body is paralyzed
Correct Answer: C
Rationale: Paraplegia is a condition characterized by the paralysis of both lower extremities. It does not affect the upper extremities or one side of the body specifically. When someone is described as a paraplegic, it means they have lost function and sensation in their lower limbs, usually due to a spinal cord injury or disease affecting the lower part of the spinal cord. This term helps provide a specific understanding of the type and location of the paralysis in the body.
Which approach would be best to use to ensure a positive response from a toddler?
- A. Assume an eye-level position and talk quietly.
- B. Call the toddler's name while picking him or her up.
- C. Call the toddler's name and say, "I'm your nurse."
- D. Stand by the toddler, addressing him or her by name.
Correct Answer: A
Rationale: The approach that would be best to use to ensure a positive response from a toddler is to assume an eye-level position and talk quietly (Option A). This approach is effective because it demonstrates respect and consideration for the toddler's perspective. By being at the child's eye level, you are showing that you are engaging with them on their level, which can help them feel more comfortable and respected. Additionally, talking quietly can help create a calm and soothing environment, which is often more conducive to getting a positive response from a toddler. This approach shows empathy and understanding towards the toddler's needs and can help in building a positive relationship with them.