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A nurse identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for metastatic cancer. What statement or question would be best to validate this client problem?
- A. I have assessed you and find you are fatigued.
- B. I analyzed and interpreted your information as fatigue.
- C. Why are you so tired all the time?
- D. I think fatigue is a problem for you. Do you agree?
Correct Answer: D
Rationale: The correct answer is D because it involves collaboration with the client to validate the identified health problem. By asking the client directly if they agree that fatigue is a problem for them, it promotes client-centered care and empowers the client in their own care. Choice A is incorrect as it assumes the nurse's assessment is enough to confirm fatigue. Choice B is incorrect as it focuses on the nurse's analysis rather than the client's experience. Choice C is incorrect because it is a closed-ended question that may not encourage open communication or validation from the client.
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A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?
- A. Place the arm in the sling
- B. Apply cold soaks to the affected arm
- C. Introduce variations in styles of clothing
- D. Tie a tight bandage to the arm
Correct Answer: C
Rationale: The correct answer is C: Introduce variations in styles of clothing. This suggestion promotes the client's self-image by helping her feel more comfortable and confident in her appearance despite the lymphedema. It allows her to express her personal style while accommodating the enlarged arm.
A: Placing the arm in a sling does not address the client's self-image concerns and may further highlight the abnormality.
B: Applying cold soaks may help with swelling but does not directly address the client's self-image.
D: Tying a tight bandage can worsen lymphedema and does not address the client's self-image concerns.
Aling Maria, a 58-year old female, was admitted for the third time because of myxedema. Initial assessment by Nurse Mida should include symptoms of:
- A. bradycardia, weight loss, heart failure, diarrhea
- B. tachycardia, constipation, exopthalmus
- C. lethargy, weight gain, slow speech, decreased RR
- D. hypothermia, weight loss, increased RR
Correct Answer: C
Rationale: The correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.
A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?
- A. Individualize the care plan only according to the patient’s needs.
- B. Request that the son leave at bedtime, so the patient can rest.
- C. Suggest that a female member of the family stay with the patient.
- D. Involve the son in the plan of care as much as possible.
Correct Answer: D
Rationale: The correct answer is D: Involve the son in the plan of care as much as possible. This is important for several reasons. Firstly, involving the son promotes family-centered care, which can improve patient outcomes. Secondly, the son may provide valuable insights into the patient's preferences and needs. Thirdly, it can help reduce the patient's confusion by providing familiar support. Option A is incorrect as it disregards the potential benefits of involving family members. Option B is incorrect as it focuses on the patient's rest without considering the emotional support the son may provide. Option C is incorrect as it assumes the gender of the family member matters more than their relationship to the patient.
Hyperparathyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
- A. Heat intolerance and systolic
- B. Diastolic hypertension and widened hypertension pulse pressure
- C. Weight gain and heat intolerance
- D. Anorexia and hyper-excitability
Correct Answer: A
Rationale: The correct answer is A because hyperparathyroidism is not caused by increased levels of thyroxine but by overactivity of the parathyroid glands. This would lead to symptoms of heat intolerance due to increased metabolism and systolic hypertension due to the effects of excess parathyroid hormone on calcium levels.
Choice B is incorrect because diastolic hypertension and widened pulse pressure are not typical symptoms of hyperparathyroidism. Choice C is incorrect because weight gain is not a common symptom of hyperparathyroidism. Choice D is incorrect because anorexia and hyper-excitability are not typical symptoms of hyperparathyroidism.
The nurse recognizes that the major early problem for Mr. Gabatan will be:
- A. Bladder control
- B. Quadriceps setting
- C. Client education
- D. Use of aids for ambulation
Correct Answer: B
Rationale: The correct answer is B: Quadriceps setting. After surgery, quadriceps setting exercises are crucial for preventing muscle atrophy and maintaining joint mobility. Bladder control (A) is important but typically not the major early problem. Client education (C) and use of aids for ambulation (D) are important aspects of care but not the primary concern immediately post-surgery. Quadriceps setting helps prevent complications and promote early mobility.