Nokea
A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:
- A. Actual Chronic Low Self-Esteem (related to obesity).
- B. Potential Chronic Low Self-Esteem (related to obesity).
- C. Actual Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
- D. Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
Correct Answer: D
Rationale: If there are indications of a body image disturbance, the nursing care plan should include body disturbances, related to a functional or physical problem. The disturbance might be an anticipated one - that is, weight gain and pregnancy. Stressors can include a change in physical appearance, sexuality concerns, or an unrealistic ideal self.
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A man reports his wife is constantly cleaning. The activity has interfered with the family life. Friends have stopped visiting because she makes them uncomfortable. He states he has awakened in the middle of the night and found her cleaning. The nurse should consult with the couple and recommend the husband help with therapy by:
- A. telling his wife to stop cleaning whenever he notices her actions
- B. making a baseline record of the time the wife spends cleaning
- C. decreasing the stimuli in the home
- D. helping his wife with the cleaning
Correct Answer: C
Rationale: Reducing environmental stimuli can decrease anxiety driving obsessive-compulsive cleaning, supporting therapy without confronting or enabling the behavior.
A client recently lost a child due to poisoning. The client tells the nurse, 'I don't want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional behavioral indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct Answer: C
Rationale: The client's withdrawal from forming new relationships reflects a sociocultural indicator of stress, as it affects social interactions. Emotional behavioral indicators involve mood changes, spiritual indicators relate to existential concerns, and intellectual indicators involve cognitive difficulties.
A client with urinary tract calculi needs to avoid which of the following foods?
- A. lettuce
- B. cheese
- C. apples
- D. broccoli
Correct Answer: B
Rationale: The client with urinary tract calculi needs to avoid cheese, which has high calcium content. The other foods do not.
A nurse is caring for a client with an elevated cortisol level. The nurse can expect the client to exhibit symptoms of:
- A. urinary excess.
- B. hyperpituitarism.
- C. urinary deficit.
- D. hyperthyroidism.
Correct Answer: C
Rationale: High levels of cortisol can produce sodium and fluid retention and potassium deficit, thus creating urinary deficit.
When helping a client gain insight into anxiety, the nurse should:
- A. help relate anxiety to specific behaviors.
- B. ask the client to describe events that precede increased anxiety.
- C. instruct the client to practice relaxation techniques.
- D. confront the client's resistive behavior.
Correct Answer: B
Rationale: To gain insight, the client needs to recognize causal events. The other activities focus on recognition of anxiety.