Nokea
In the nursing diagnosis 'Disturbed Self-Esteem related to presence of large scar over left side of face,' what part of the nursing diagnosis is 'presence of large scar over left side of face'?
- A. Etiology
- B. Problem
- C. Defining characteristics
- D. Client need
Correct Answer: A
Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors that lead to the identified problem. In this case, the presence of a large scar over the left side of the face is the underlying cause of the disturbed self-esteem. It directly influences the client's self-perception and self-worth. The problem (B) is the disturbed self-esteem itself, not the scar. Defining characteristics (C) are the signs and symptoms that support the nursing diagnosis. Client need (D) is a broader concept that encompasses the overall needs of the client, whereas etiology specifically focuses on the cause of the problem.
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When assessing a client with a disorder of the hematopoietic or the lymphatic, why is it important for the nurse to obtain a dietary history?
- A. Compromised nutrition interferes with the production of blood cells and hemoglobin
- B. Diet consisting of excessive fat interferes with the production of blood cells and haemoglobin
- C. Inconsistent dieting interferes with the production of blood cells and haemoglobin
- D. Diet consisting of excessive iron and protein elements interferes with the production of blood cells and haemoglobin
Correct Answer: A
Rationale: The correct answer is A because compromised nutrition can lead to deficiencies in essential nutrients required for the production of blood cells and hemoglobin. Iron, vitamins, and minerals obtained from food are crucial for erythropoiesis and maintaining a healthy immune system. Without these nutrients, the body may struggle to produce an adequate amount of healthy red blood cells, leading to anemia and compromised immune function.
Choice B is incorrect because excessive fat in the diet is not directly linked to interfering with the production of blood cells and hemoglobin. Choice C is incorrect as inconsistent dieting may affect overall health but is not specifically related to hematopoiesis. Choice D is incorrect because while iron and protein are important for blood cell production, excessive amounts of these elements are unlikely to interfere with the production of blood cells and hemoglobin.
A woman sees her primary care provider because of extreme fatigue for the past 2 months; she difficulty lifting even light objects. Her physician suspects myasthenia gravis. Which of the ff. tests should the nurse anticipate to confirm this diagnosis?
- A. Mestinon test
- B. Pulmonary function studies
- C. Quinine tolerance test
- D. Tensilon test
Correct Answer: D
Rationale: The correct answer is D: Tensilon test. The Tensilon test involves administering edrophonium (Tensilon) to temporarily improve muscle weakness in myasthenia gravis patients, confirming the diagnosis. Other choices are incorrect: A (Mestinon test) is not a standard diagnostic test for myasthenia gravis, B (Pulmonary function studies) are not specific for myasthenia gravis, and C (Quinine tolerance test) is not a relevant test for this condition.
Which of the ff actions should the nurse perform before a client with impaired physical mobility gets up?
- A. Use parallel bars or a walker
- B. Use incontinence pads
- C. Apply an abdominal binder
- D. Use a footboard
Correct Answer: A
Rationale: The correct answer is A: Use parallel bars or a walker. Before a client with impaired physical mobility gets up, the nurse should provide assistive devices like parallel bars or a walker to ensure safe and supported ambulation. This helps prevent falls and promotes independence. Using incontinence pads (B) is not directly related to mobility. Applying an abdominal binder (C) is not necessary before the client gets up. Using a footboard (D) is more relevant for positioning in bed, not for assisting with ambulation.
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client’s care, the nurse should focus on his need for:
- A. Pain management
- B. Antiretroviral therapy
- C. Fluid replacement
- D. High-calorie intake
Correct Answer: C
Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (A) may be needed for discomfort but is not the priority. Antiretroviral therapy (B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because it is important for the nurse to communicate directly with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter may undermine the patient's autonomy and dignity. It is crucial for the nurse to establish rapport and build a therapeutic relationship with the patient. Making eye contact with the patient (choice A) is a good nonverbal communication technique. Leaning forward while talking with the patient (choice C) shows attentiveness and engagement. Nodding periodically while the patient is speaking (choice D) demonstrates active listening and encourages the patient to continue sharing. However, speaking only to the patient's daughter (choice B) is the incorrect choice as it neglects the patient's role in the conversation and may lead to potential issues in communication and patient-centered care.