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A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
- A. Risk for impaired physical mobility due to surgery
- B. Ineffective denial related to poor coping mechanisms
- C. Disturbed body image related to the incision scar
- D. Risk of injury related to surgical outcomes
Correct Answer: C
Rationale: The correct answer is C: Disturbed body image related to the incision scar. This nursing diagnosis is appropriate as the client's concern about wearing a scarf post-surgery indicates a potential disturbance in body image due to the visible scar. The nurse should address the client's emotional response and offer support to help cope with the change in appearance.
A: Risk for impaired physical mobility due to surgery - This choice is not directly related to the client's worry about wearing a scarf and focuses more on physical limitations post-surgery.
B: Ineffective denial related to poor coping mechanisms - This choice does not address the specific body image concern expressed by the client.
D: Risk of injury related to surgical outcomes - This choice does not address the client's emotional response to the scar and focuses on physical safety risks instead.
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A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. This is because soap can irritate the skin, leading to skin breakdown in a client at risk for impaired skin integrity due to radiation therapy. Avoiding soap helps to prevent further damage to the skin.
Choice B is incorrect as talcum powder can further irritate the skin and should be avoided. Choice C is not relevant to preventing skin integrity issues. Choice D is incorrect because thoracic skin markings should not be removed as they are essential for accurate radiation delivery.
A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
- A. Equipment
- B. Safe environment
- C. Confidence
- D. Assistive personnel
Correct Answer: A
Rationale: The correct answer is A: Equipment. The nurse needs to ensure that necessary equipment is available to carry out interventions effectively and safely. Without the right equipment, the nurse may not be able to provide appropriate care. Safe environment (B) is important but not a resource that the nurse makes sure is available. Confidence (C) is a personal attribute and not a resource. Assistive personnel (D) are individuals who can help but are not resources that the nurse ensures are available.
A 61-year old female patient with diabetes is in the emergency department after stepping on a sharp onject while walking barefoot on the beach. The patient did not notice that the object pierced the skin unitl later that evening. What problem does she probably have?
- A. neuropathy on her peripheral
- B. nephropathy
- C. carpal tunnel syndrome
- D. macroangiopathy
Correct Answer: A
Rationale: The correct answer is A: neuropathy on her peripheral. In diabetes, peripheral neuropathy is common, causing loss of sensation in the feet, making it difficult to feel injuries like stepping on a sharp object. This can lead to delayed detection of wounds, increasing the risk of infections and complications. Nephropathy (B) refers to kidney damage, carpal tunnel syndrome (C) involves compression of the median nerve in the wrist, and macroangiopathy (D) refers to large blood vessel disease, which are not directly related to the scenario described.
What is an example of a nurse modifying the care plan during the evaluation phase?
- A. Adding a new intervention to address an unmet goal.
- B. Performing routine monitoring of the client’s condition.
- C. Administering medication as prescribed by the physician.
- D. Completing discharge paperwork for the client.
Correct Answer: A
Rationale: The correct answer is A because modifying the care plan during the evaluation phase involves making changes based on the client's response to interventions. By adding a new intervention to address an unmet goal, the nurse demonstrates critical thinking and adaptability in response to the client's needs. This action shows that the nurse is actively assessing and revising the care plan to ensure it is effective in meeting the client's goals.
Choice B is incorrect because routine monitoring is part of the assessment and implementation phases, not specifically related to modifying the care plan during evaluation. Choice C is incorrect as administering medication is part of the implementation phase and does not necessarily involve modifying the care plan. Choice D is also incorrect as completing discharge paperwork is typically part of the discharge planning phase, not the evaluation phase where modifications to the care plan are made based on client outcomes.
Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
- A. Antibiotics as needed
- B. Bedrest
- C. Elevate the head of bed
- D. Suction q4h
Correct Answer: C
Rationale: The correct answer is C: Elevate the head of bed. Elevating the head of the bed helps improve lung expansion and ventilation, making it easier for patients with impaired respiratory function to breathe. This position also helps prevent aspiration and reduces the risk of respiratory complications. Antibiotics (choice A) are not indicated unless specifically prescribed for an infection. Bedrest (choice B) can lead to deconditioning and worsen respiratory function. Suctioning (choice D) every 4 hours is not necessary unless there is excessive secretions present.