Nokea
A woman is scheduled for a breast biopsy. She is crying and says, 'I am so upset because I watched my mother die from ovarian cancer.' What is the most appropriate nursing diagnosis?
- A. Fear
- B. Anxiety
- C. Ineffective family coping
- D. Spiritual distress
Correct Answer: A
Rationale: Fear of cancer due to her mother's death is the most specific diagnosis, addressing her emotional response to the biopsy.
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The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:
- A. disclose the information before the child knows or suspects.
- B. be comfortable with your sexual preference first.
- C. have the discussion in a quiet place where interruptions are unlikely.
- D. explain how your relationship with the child changes because of the discussion.
Correct Answer: D
Rationale: Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion.
A laboring woman who has dystocia is receiving oxytocin. The nurse observes a contraction lasting 90 seconds. What should the nurse do first?
- A. Slow down the rate of the oxytocin
- B. Turn the woman on her left side
- C. Give the woman oxygen
- D. Stop the oxytocin
Correct Answer: D
Rationale: Contractions longer than 60-90 seconds risk fetal hypoxia; stopping oxytocin immediately reduces uterine stimulation, prioritizing fetal safety.
The nurse is caring for a client who is postoperative day 1 after a nephrectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Urine output of 30 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-nephrectomy requiring immediate evaluation. Options B, C, and D are expected or normal: incision pain is typical, urine output 30 mL/hour is adequate for one kidney, and blood pressure 130/80 mmHg is stable.
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone.
- A. Which nursing diagnosis is a priority for a client with left-sided hemiparesis post-CVA?
- B. Alteration in mobility related to paralysis.
- C. Alteration in skin integrity related to decrease in tissue oxygenation.
- D. Alteration in skin integrity related to immobility.
- E. Alteration in communication related to decrease in thought processes.
Correct Answer: B
Rationale: Decreased tissue oxygenation from impaired circulation in hemiparesis is the leading cause of skin breakdown, making this the priority nursing diagnosis. Mobility and immobility are concerns, but tissue perfusion is more critical, and communication issues are more relevant to right-sided CVA.
On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:
- A. Decrease the rate of the intravenous infusion.
- B. Change the type of intravenous fluid being administered.
- C. Change the urinary catheter.
- D. Increase the rate of the intravenous infusion.
Correct Answer: D
Rationale: The urinary output should be maintained between 30 ml and 50 ml per hour. The first action should be to increase the IV rate to prevent increased acidosis. Answer A would lead to diminished output, so it is incorrect. There is no indication that the type of IV fluid is not appropriate as is suggested by answer B, making it incorrect. Answer C would not increase the client's output and would place the client at greater risk for infection, so it is incorrect.