Nokea
A nurse has assessed that a patient is not yet willing to view her mastectomy site. How should the nurse best assist the patient is developing a positive body image?
- A. Ask the woman to describe the current appearance of her breast.
- B. Help the patient to understand that many women have gone through the same unpleasant experience.
- C. Explain to the patient that her body image does not have to depend on her physical appearance.
- D. Provide the patient with encouragement in an empathic and thoughtful manner.
Correct Answer: D
Rationale: Step 1: Providing encouragement is essential to building trust and rapport with the patient, which is crucial in supporting her emotional needs.
Step 2: Empathy helps the patient feel understood and supported, fostering a positive therapeutic relationship.
Step 3: Thoughtful encouragement acknowledges the patient's feelings and validates her experiences, empowering her to gradually accept her body changes.
Step 4: By offering empathic and thoughtful encouragement, the nurse helps the patient develop a positive body image at her own pace.
Choice A focuses on physical appearance, Choice B generalizes experiences, and Choice C overlooks the patient's emotional journey.
You may also like to solve these questions
A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the
nurse expect?
- A. Distended abdomen
- B. Decreased skin turgor
- C. Increased energy levels
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss, causing dehydration and decreased skin turgor. This indicates the patient's hydration status. A: Distended abdomen is more common in conditions like bowel obstruction, not necessarily in diarrhea. C: Increased energy levels are unlikely due to the patient's weakened state from dehydration. D: Elevated blood pressure is not typically associated with dehydration.
The nurse is describing some of the major characteristics of cancer to a patient who has recently received a diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse should explain differences in which of the following aspects? Select all that apply.
- A. Rate of growth
- B. Ability to cause death
- C. Size of cells
- D. Cell contents E) Ability to spread
Correct Answer: A
Rationale: The correct answer is A: Rate of growth. Malignant cancer cells grow and divide rapidly compared to benign cells. Benign cells are usually slow-growing and have a well-defined border, while malignant cells grow uncontrollably and invade surrounding tissues. The other choices are incorrect because: B: Ability to cause death - Both benign and malignant cells have the potential to cause harm, but the key difference lies in their growth rate and invasiveness. C: Size of cells - The size of cells does not necessarily differentiate between benign and malignant cells. D: Cell contents - While malignant cells may have abnormal cell contents, this is not a defining characteristic when differentiating between benign and malignant cells. E: Ability to spread - While the ability to spread is a key characteristic of malignant cells, the primary differentiating factor in this question is the rate of growth.
A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply.
- A. Foods
- B. Medications
- C. Insect stings
- D. Autoimmunity E) Environmental pollutants
Correct Answer: A
Rationale: The correct answer is A: Foods. Anaphylaxis is a severe allergic reaction that can be triggered by foods, medications, insect stings, and other allergens. In this scenario, assessing for potential food allergies is crucial as food is one of the most common triggers for anaphylaxis. Foods like nuts, shellfish, and eggs are common culprits. Medications and insect stings (choices B and C) are also important triggers to consider in the assessment. Autoimmunity (choice D) is not a direct cause of anaphylaxis, as it involves the immune system attacking the body's own tissues rather than reacting to external allergens. Environmental pollutants (choice E) may trigger respiratory symptoms but are not typically associated with anaphylaxis.
When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
- A. Loss of muscle tone in the vaginal wall
- B. Excessive synthesis and release of unopposed estrogen
- C. Invasion of the uterine wall by endometrial tissue
- D. Proliferation of tumors in the uterine wall
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus.
Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall.
Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis.
Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
- A. From the tip of the nose to the earlobe
- B. From the tip of the earlobe to the xiphoid process
- C. From the tip of the earlobe to the nose to the xiphoid process
- D. From the tip of the nose to the earlobe to the xiphoid process
Correct Answer: C
Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement.
Summary of Incorrect Choices:
A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach.
B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage.
D: Measuring from the tip of the nose to the earlobe to