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or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. "Client verbalizes feelings of anxiety."
- B. "Client doesn't guess at prognosis."
- C. "Client uses any effective method to reduce tension."
- D. "Client stops seeking information."
Correct Answer: C
Rationale: The most appropriate expected outcome for a client experiencing anxiety related to a cancer diagnosis would be "Client uses any effective method to reduce tension." This outcome focuses on the client actively managing their anxiety by utilizing various strategies to decrease tension and promote feelings of calmness. It empowers the client to take control of their anxiety and seeks to foster a sense of well-being during a difficult time. The other options do not directly address the active management of anxiety as effectively as option C.
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Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: B
Rationale: The outcome that indicates successful fluid resuscitation in managing diarrhea is when the patient reports a decrease in stool frequency and liquidity. This is because diarrhea is characterized by an increase in stool frequency and liquidity due to the body's attempt to expel irritants or infections. By successfully resuscitating with fluids, the goal is to rehydrate the body and restore electrolyte balance, which should lead to a decrease in stool frequency and formation of more solid stools. This improvement in stool consistency and frequency is a clear indicator that the fluid resuscitation has been effective in treating the diarrhea. Therefore, option B is the correct choice for the outcome indicating successful fluid resuscitation in this scenario.
Appropriate intervention is vital for many children with heart disease in order to go on to live active, full lives. Which of the following outlines an effective nursing intervention to decrease cardiac demands and minimize cardiac workload?
- A. Feeding the infant over long periods
- B. Allowing the infant to have her way to avoid conflict
- C. Scheduling care to provide for uninterrupted rest periods
- D. Developing and implementing a consistent care plan
Correct Answer: C
Rationale: The most appropriate intervention to decrease cardiac demands and minimize cardiac workload in children with heart disease is to schedule care to provide uninterrupted rest periods. By allowing the child to rest without interruptions, their heart will not have to work as hard, promoting better overall cardiac function. This intervention focuses on promoting rest and recovery, which is crucial for children with heart disease to maintain optimal cardiac health. Feeding the infant over long periods may not necessarily decrease cardiac demands, and allowing the infant to have her way to avoid conflict is not related to cardiac workload. Developing and implementing a consistent care plan is important but may not directly decrease cardiac demands as effectively as scheduling care for uninterrupted rest periods.
When teaching a client about insulin therapy, the nurse should instruct the client to avoid which over-the- counter preparation that can interact with insulin?
- A. Antacids
- B. Vitamins with irons
- C. Acetaminophen preparations
- D. Salicylate preparations
Correct Answer: D
Rationale: Salicylates, such as aspirin, can potentiate the hypoglycemic effects of insulin. They can increase insulin sensitivity and potentially lead to low blood sugar levels (hypoglycemia). Therefore, clients using insulin should avoid over-the-counter salicylate preparations to prevent this interaction and the risk of hypoglycemia. It is important for clients to always consult healthcare professionals before taking any new medications or over-the-counter preparations when using insulin therapy.
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
- A. Hypotension
- B. Hives or rashes
- C. Localized inflammation
- D. Cramping and vomiting
Correct Answer: B
Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.
In embryonic period, all are true EXCEPT
- A. formation of ectoderm by 8 days
- B. formation of mesoderm by 10 weeks
- C. formation of endoderm by 3 cm crown-rump length
- D. formation of human embryo is about 6 weeks
Correct Answer: D
Rationale: The formation of the human embryo is completed by 8 weeks, not 6 weeks.