Nokea
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
- A. Anxiety related to the presence of a urinary diversion.
- B. Deficient knowledge about how to care for the urinary diversion.
- C. Low self-esteem related to feelings of worthlessness.
- D. Unstuffed body image related to creation of a urinary diversion.
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
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Which of the following clients is most at risk for potential hazards from the surgical experience?
- A. A 68-year-old client.
- B. A 48-year-old client.
- C. A 30-year-old client.
- D. A 13-year-old client.
Correct Answer: A
Rationale: The 68-year-old client is most at risk due to age-related declines in organ function, slower recovery, and higher likelihood of comorbidities, increasing surgical complications.
A 62-year-old Chinese man is admitted with multiple injuries from a motor vehicle accident. He complains of severe pain and requests frequent medication. One of the assistive nursing personnel expresses surprise, saying, "I thought Asian people were very stoic about pain." Which is the nurse's best response about pain?
- A. Expression and perception of pain vary widely from person to person.
- B. Tolerance of pain is the same in all people.
- C. Tolerance of pain is determined by a person's genetic makeup.
- D. Pain perception is the same in all people.
Correct Answer: A
Rationale: Pain expression and perception vary individually due to cultural, personal, and situational factors, countering the stereotype. Pain tolerance and perception are not uniform or solely genetic.
Which of the following would be a significant intervention to help prevent lung cancer?
- A. Encourage cigarette smokers to have yearly access to drugs.
- B. Instruct people about techniques for smoking cessation.
- C. Recommend that people have their houses and apartments checked for asbestos leakage.
- D. Encourage people to install central air cleaners in their homes.
Correct Answer: B
Rationale: Smoking cessation is the most effective intervention to prevent lung cancer, as smoking is the leading cause. Screening (not 'access to drugs'), asbestos checks, and air cleaners are less impactful.
The following scenario applies to the next 1 items
The emergency department nurse cares for a child with otitis media
Item 1 of 1
Nurses' Note
Vital Signs
Orders
1815: 10-year-old-male arrives at the emergency department (ED) after reporting a fever, left ear pain, and malaise that started three days ago and has worsened. The client's father reports that he was at a pool party a few days before the symptoms started. The child is alert and fully oriented. Warm to touch and reports that 'it hurts a lot.' The left ear was slightly reddened with no drainage. Peripheral pulses were palpable. Lung sounds were clear. Reports no coughing or other symptoms. The child does not have any medical history. No known allergies. Current on all immunizations. Current weight is 33 kilograms (kg).
The nurse should administer the ceftriaxone in the client's ............................……. to prevent............................……….. The nurse should obtain a prescription for ............................…. cream to apply one hour before the injection to decrease the child's pain.
- A. ventrogluteal
- B. dorsogluteal
- C. Abdomen
- D. nerve damage.
- E. staining of the skin
- F. hydrocortisone
- G. EMLA (lidocaine and prilocaine)
Correct Answer: A,D,G
Rationale: Ceftriaxone should be administered in the ventrogluteal site to avoid nerve damage; EMLA cream reduces pain when applied an hour prior.
The nurse is performing discharge education to an older adult diagnosed with cataracts. Which of the following statements indicates effective understanding?
- A. I may have to quit driving until I get the cataracts treated.'
- B. I should spend less time outdoors in the sun and plan more activities at night.'
- C. I will need to avoid activities that raise my intraocular pressure, such as bending at the waist.'
- D. I will have to be careful since my eyes won't move together.'
Correct Answer: A
Rationale: Cataracts can impair vision, making driving unsafe until treated. Sun exposure does not directly affect cataracts, intraocular pressure is not a primary concern, and eye movement misalignment is not typical.