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A nurse is assessing the patient’s meaning ofillness. Which area of focus by the nurse ispriority?
- A. On the way a patient reacts to disease
- B. On the malfunctioning of biological processes
- C. On the malfunctioning of psychological processes
- D. On the way a patient reacts to family/social interactions
Correct Answer: A
Rationale: The correct answer is A because understanding how a patient perceives and reacts to their illness is crucial for providing holistic care. By focusing on the patient's perspective, the nurse can address their emotional, mental, and social needs. Choice B is incorrect as it only considers biological aspects. Choice C is incorrect as it only focuses on psychological processes. Choice D is incorrect as it does not directly address the patient's perspective on illness. A holistic approach that considers the patient's meaning of illness is essential for providing patient-centered care.
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A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear?
- A. Yellowish-white
- B. Pink
- C. Gray
- D. Bluish-white
Correct Answer: B
Rationale: The correct answer is B: Pink. In a healthy ear, the tympanic membrane should appear pink due to the rich blood supply. This color indicates good vascularization and normal functioning of the ear. Yellowish-white (choice A), gray (choice C), and bluish-white (choice D) are incorrect because they do not reflect the normal color of a healthy tympanic membrane. Yellowish-white may indicate fluid behind the eardrum, gray may suggest infection or inflammation, and bluish-white could indicate poor blood flow or trauma. Therefore, the pink color of the tympanic membrane is the most appropriate and indicative of a healthy ear in this case.
A nurse is caring for patients with dysphagia. Which patient has neurogenic dysphagia?
- A. A patient with benign peptic stricture
- B. A patient with muscular dystrophy
- C. A patient with myasthenia gravis
- D. A patient with stroke
Correct Answer: D
Rationale: The correct answer is D because neurogenic dysphagia is caused by neurological conditions affecting swallowing function, such as a stroke. In a stroke, damage to the brain can impair the coordination of swallowing muscles, leading to dysphagia.
Choice A is incorrect because benign peptic stricture is a narrowing of the esophagus due to chronic acid reflux, not a neurological issue.
Choice B is incorrect because muscular dystrophy is a genetic disorder that affects muscle strength and does not directly impact the neurological control of swallowing.
Choice C is incorrect because myasthenia gravis is an autoimmune disorder that affects neuromuscular transmission but is not typically associated with neurogenic dysphagia.
A 29-year-old patient has just been told that he has testicular cancer and needs to have surgery. During a presurgical appointment, the patient admits to feeling devastated that he requires surgery, stating that it will leave him emasculated and a shell of a man. The nurse should identify what nursing diagnosis when planning the patients subsequent care?
- A. Disturbed Body Image Related to Effects of Surgery
- B. Spiritual Distress Related to Effects of Cancer Surgery
- C. Social Isolation Related to Effects of Surgery
- D. Risk for Loneliness Related to Change in Self-Concept
Correct Answer: A
Rationale: The correct answer is A: Disturbed Body Image Related to Effects of Surgery. This nursing diagnosis is appropriate because the patient expresses concerns about feeling emasculated and a shell of a man after the surgery, indicating a disturbance in his body image. The patient's perception of how the surgery will affect his masculinity is a clear indication of body image disturbance.
Choice B is incorrect because there is no mention of spiritual distress in the patient's statements. Choice C is incorrect as there is no indication that the patient will experience social isolation specifically related to the surgery. Choice D is incorrect as the patient's concerns are primarily related to his body image and not loneliness.
Which finding in the assessment of a patient following an abruption placenta could indicate a major complication?
- A. Urine output of 30 mL in 1 hour
- B. Blood pressure of 110/60 mm Hg
- C. Bleeding at IV insertion site
- D. Respiratory rate of 16 breaths per minute
Correct Answer: C
Rationale: The correct answer is C - bleeding at IV insertion site. This finding could indicate a major complication following an abruption placenta, such as disseminated intravascular coagulation (DIC) or hypovolemic shock. Bleeding at the IV site suggests a systemic issue affecting the patient's coagulation status. Choices A, B, and D are not directly indicative of a major complication following an abruption placenta. Urine output, blood pressure, and respiratory rate are important parameters to monitor but do not specifically point to a major complication in this context.
The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, “How much fat should I have? I guess the less fat, the better.” Which information will the nurse include in the teaching session?
- A. Cholesterol intake needs to be less than 300 mg/day.
- B. Fats have no significance in health and the incidence of disease.
- C. All fats come from external sources so this can be easily controlled.
- D. Deficiencies occur when fat intake falls below 10% of daily nutrition.
Correct Answer: D
Rationale: The correct answer is D: Deficiencies occur when fat intake falls below 10% of daily nutrition.
Rationale:
1. Fat is essential for absorption of fat-soluble vitamins (A, D, E, K) and for maintaining healthy cell membranes.
2. Fat provides essential fatty acids (omega-3, omega-6) crucial for brain function and inflammation regulation.
3. Adequate fat intake prevents deficiencies like dry skin, poor wound healing, and hormonal imbalances.
4. A low-fat diet should still include at least 10% of daily nutrition from healthy fats for optimal health.
Summary:
A: Cholesterol intake is important but not the primary focus for a low-fat diet.
B: Fats are significant for health, and extreme low-fat diets can lead to deficiencies.
C: While some fats are from external sources, the body needs a minimum amount for proper functioning.