Nokea
A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?
- A. “I’m worried about what those other girls will think of me.”
- B. “I can’t wear that color. It makes my hips stick out.”
- C. “I’ll wear the blue dress. It matches my eyes.”
- D. “I will go to the pool next summer.”
Correct Answer: C
Rationale: The correct answer is C because it shows a positive self-perception and self-acceptance. By choosing the dress based on how it complements her eyes, the patient demonstrates a focus on her own preferences and self-image rather than external validation or criticism. This indicates progress towards accepting her body image.
A: Choice A indicates concern about others' opinions, which shows a lack of self-assurance and reliance on external validation.
B: Choice B reflects negative body image and self-criticism, indicating a lack of acceptance.
D: Choice D is focused on a future event, suggesting avoidance or delay in addressing the current body image issues.
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Which of the following diets would the nurse include in the plan of care for a person with AIDS?
- A. A high-protein, high-calorie diet divided into six small meals.
- B. A low-fat, soft diet divided into 8 small meals.
- C. A high-carbohydrate, fat-restricted diet divided into 4 meals.
- D. A high-fat, high-calorie diet divided into 3 meals.
Correct Answer: A
Rationale: The correct answer is A: A high-protein, high-calorie diet divided into six small meals. For a person with AIDS, this diet is beneficial to maintain muscle mass, support immune function, and provide energy. High-protein helps in tissue repair, while high-calorie intake helps combat weight loss common in AIDS. Dividing into small frequent meals aids in digestion and absorption.
Choice B is incorrect because a low-fat diet may not provide enough calories for the increased energy needs of a person with AIDS. Choice C is incorrect because a high-carbohydrate, fat-restricted diet may not provide sufficient protein for muscle maintenance. Choice D is incorrect because a high-fat diet may lead to weight gain and can be harder to digest for someone with compromised immunity.
A woman with pelvic inflammatory disease complains of lower abdominal pain. Which action should the nurse take first?
- A. Have her rate her pain on a 0 to 10 scale
- B. Administer antibiotics as ordered
- C. Administer an analgesic as ordered
- D. Teach the patient about causes and prevention of STDs
Correct Answer: B
Rationale: The correct action is to administer antibiotics as ordered first because pelvic inflammatory disease is caused by an infection, usually from sexually transmitted organisms. Administering antibiotics promptly is crucial to prevent further complications and treat the underlying infection. This helps to alleviate the source of the pain. Rating pain severity, administering analgesics, and patient education are important but should come after addressing the infection to prevent worsening of the condition.
The client is a type II DM patient. The client asks the nurse what is the primary reason a type II diabetic does not usually develop diabetic ketoacidosis?
- A. there is no insulin available for the state of hyperglycemia
- B. the type II diabetic has no protein of fat reserves
- C. there is no sufficient insulin to prevent the breakdown of protein and fatty acid for metabolic needs
- D. there is insufficient serum glucose concentrations
Correct Answer: C
Rationale: Rationale for Choice C (Correct answer):
- In type II DM, there is some insulin present but it is insufficient to meet the body's needs.
- Without sufficient insulin, the body turns to breaking down protein and fatty acids for energy.
- This leads to the formation of ketones, which can lead to diabetic ketoacidosis (DKA).
- Therefore, the primary reason a type II diabetic does not usually develop DKA is due to insufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs.
Summary of other choices:
- Choice A is incorrect because there is some insulin available in type II DM, though it may be insufficient.
- Choice B is incorrect as type II diabetics do have fat and protein reserves.
- Choice D is incorrect as insufficient serum glucose concentrations do not directly relate to the development of DKA in type II DM.
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
- A. The patient’s room with the door closed
- B. The waiting area with the television turned off
- C. The patient’s room before administration of pain medication
- D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B
Rationale: The correct answer is B because conducting the interview in a quiet environment, like the waiting area with the television turned off, reduces background noise and distractions for the patient with a hearing deficit. This allows for better communication and understanding.
A: Conducting the interview in the patient's room with the door closed may still have distractions or noise from outside the room.
C: Conducting the interview in the patient's room before administration of pain medication does not address the issue of reducing background noise for better communication.
D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional distractions and noise, making it harder for the patient with a hearing deficit to communicate effectively.
In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?
- A. Positive family history
- B. Infectious agents or toxins
- C. Acute or chronic blood loss
- D. Inadequate dietary intake
Correct Answer: A
Rationale: The correct answer is A: Positive family history. Pernicious anemia is an autoimmune condition where the body attacks its own intrinsic factor, leading to vitamin B12 deficiency. Genetic predisposition plays a significant role in the development of pernicious anemia. Family history is a key risk factor as individuals with a family history of pernicious anemia are more likely to develop the condition.
Summary of why the other choices are incorrect:
B: Infectious agents or toxins do not directly cause pernicious anemia, although they can lead to other types of anemia.
C: Acute or chronic blood loss can result in iron-deficiency anemia, not pernicious anemia.
D: Inadequate dietary intake of vitamin B12 can lead to vitamin B12 deficiency anemia, but pernicious anemia specifically involves the body's inability to absorb B12 due to intrinsic factor deficiency, not dietary intake alone.