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Ms. C(an adolescent admitted for diagnostic evaluation and nutritional support related to anorexia nervosa)'s self-esteem and weight have gradually improved, but she continues to refer to herself as "fatty." She is able to appropriately verbalize an appropriate diet and exercise plan. What is the priority nursing diagnosis?
- A. Imbalanced Nutrition: less than body requires
- B. Risk for situational low self-esteem
- C. Disturbed body image
- D. Ineffective health maintenance
Correct Answer: C
Rationale: Even though Ms. C's self-esteem and weight have improved, her continued negative self-talk and use of derogatory terms like "fatty" indicate a distorted perception of her body image. This distortion needs to be addressed and corrected for her overall long-term psychological well-being. By focusing on addressing the disturbed body image, the nursing team can help Ms. C develop a more positive self-perception and maintain the progress she has made towards recovery from anorexia nervosa. It is important to prioritize interventions that promote a healthier and more realistic body image in order to support her ongoing recovery journey.
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Patient was visited by the anesthesiologist and explained the anesthesia for his surgery. Which of the following type of anesthesia would you expect to be ordered?
- A. Spinal
- B. Local
- C. Caudal
- D. General
Correct Answer: D
Rationale: When the anesthesiologist visits a patient to explain the anesthesia for surgery, the most likely type of anesthesia to be ordered in this scenario would be general anesthesia. General anesthesia is a state of controlled unconsciousness where the patient is completely unaware and unresponsive during the procedure. This type of anesthesia is typically used for surgeries that are more complex, lengthy, or invasive, requiring the patient to be completely still and asleep throughout the operation.
Patient Hydee asks how she could Distinguish between true and false labor? Which is NOT included among the factors in which the nurse should base her answer from?
- A. Contractions
- B. Cervical by vaginal examination
- C. Vital signs
- D. Engagement of fetus
Correct Answer: D
Rationale: The engagement of the fetus refers to the baby's head moving down into the mother's pelvis in preparation for birth. This factor is not typically used to distinguish between true and false labor because it is a sign of progress in labor rather than a defining characteristic of true labor. In contrast, the factors that are commonly used to differentiate between true and false labor include contractions (e.g., regularity, intensity, duration), cervical changes observed through vaginal examination (e.g., effacement and dilation), and monitoring vital signs.
Mang Emilio refuses to take his daily medication for hypertension. Which of the following actions should Nurse Pedrito take at this time?
- A. Tell MangEmilio that he will suffer from stroke.
- B. Explore the reason for the client's refusal to take the medication.
- C. Administer the medication by injection.
- D. Obtain help from relatives in administering the medication.
Correct Answer: B
Rationale: The most appropriate action for Nurse Pedrito to take at this time is to explore the reason for Mang Emilio's refusal to take his daily medication for hypertension. By understanding the underlying cause of his refusal, Nurse Pedrito can address any concerns or barriers that may be preventing Mang Emilio from adhering to his medication regimen. This approach emphasizes the importance of patient-centered care and communication in promoting medication compliance and overall health outcomes. Additionally, it allows Nurse Pedrito to work collaboratively with Mang Emilio to find a solution that meets his needs and preferences.
A 55-year-old postmenopausal woman presents with vaginal bleeding. On pelvic examination, the cervix appears healthy, and there is no cervical motion tenderness. Which of the following conditions is most likely to be responsible for these findings?
- A. Cervical cancer
- B. Endometrial cancer
- C. Vaginal cancer
- D. Cervical polyp
Correct Answer: D
Rationale: In a 55-year-old postmenopausal woman presenting with vaginal bleeding and a healthy cervix on examination, the most likely cause would be a cervical polyp. Cervical polyps are benign growths that can occur on the cervix and are often asymptomatic but can occasionally cause postmenopausal bleeding. Their appearance on examination would typically be a non-malignant finding with no cervical motion tenderness. Cervical cancer, endometrial cancer, and vaginal cancer would typically present with different examination findings and risk factors.
A patient presents with a thyroid nodule and signs of compression such as difficulty swallowing and breathing. Fine-needle aspiration biopsy reveals lymphocytic infiltration and germinal centers. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hashimoto's thyroiditis
- B. Graves' disease
- C. Diabetes mellitus
- D. Thyroid nodules
Correct Answer: A
Rationale: Hashimoto's thyroiditis is an autoimmune disorder characterized by chronic inflammation of the thyroid gland. In this condition, lymphocytic infiltration and germinal centers can be seen in the thyroid tissue. This inflammation can lead to the formation of thyroid nodules and enlargement of the thyroid gland, causing symptoms such as difficulty swallowing and breathing due to compression of surrounding structures. Additionally, Hashimoto's thyroiditis can result in hypothyroidism over time, further contributing to the symptoms. Therefore, the patient in this case is most likely experiencing these symptoms due to Hashimoto's thyroiditis. Graves' disease, on the other hand, typically presents with hyperthyroidism and is less likely to manifest as compressive symptoms of the thyroid gland.