Nokea
The client with a laryngectomy communicates to the nurse that he does not want his family to see him. He indicates that he thinks the opening in his throat is disgusting. Which of the following nursing diagnoses would be most appropriate?
- A. Deficient knowledge about the care of a stoma.
- B. Disturbed personal identity related to change in appearance.
- C. Disturbed body image related to neck surgery.
- D. Hopelessness related to irreversible changes in body functioning.
Correct Answer: C
Rationale: Disturbed body image related to neck surgery addresses the client's negative feelings about the stoma's appearance. Deficient knowledge is less relevant here. Disturbed personal identity is broader. Hopelessness implies a deeper psychological state not fully supported by the description.
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A client who underwent a left lower lobectomy has been out of surgery for 48 hours. She is receiving morphine sulfate via a patient-controlled analgesia (PCA) system. She tells the nurse that she has some pain in her left thorax that worsens when she coughs. The nurse should:
- A. I don't be silent, so that she is not stimulated to cough.
- B. Encourage the client to take deep breaths to help control the pain.
- C. Check that the PCA device is functioning properly, and then reassure the client that the machine is working and will relieve her pain.
- D. Obtain a more detailed assessment of the client's pain using a pain scale.
Correct Answer: D
Rationale: A detailed pain assessment using a scale clarifies the pain's severity and guides adjustments to analgesia. Silencing the client or encouraging deep breaths may worsen pain. Checking the PCA is appropriate but secondary to assessment.
The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?
- A. Decreased cardiac output.
- B. Pleural effusion.
- C. Inadequate peripheral circulation.
- D. Decreased oxygenation of the blood.
Correct Answer: D
Rationale: Cyanosis in pneumonia results from decreased blood oxygenation due to impaired gas exchange in the lungs. Cardiac output, pleural effusion, and peripheral circulation may contribute but are not primary causes.
Which of the following is an expected outcome when a client is receiving an I.V. administration of furosemide?
- A. Increased blood pressure.
- B. Increased urine output.
- C. Decreased pain.
- D. Decreased premature ventricular contractions.
Correct Answer: B
Rationale: Furosemide, a loop diuretic, promotes diuresis, increasing urine output to reduce fluid overload in conditions like heart failure or post-MI.
A 66-year-old female who is usually meticulous about her appearance and dress arrives today for her 23rd day of radiation therapy and appears disheveled and emotionally labile, and her responses to the usual questions are a little inappropriate. Her heart rate is 124 bpm, her respirations are 32 breaths/minute, and her skin is cold and clammy. These findings would suggest that the nurse should further assess the client for which of the following conditions?
- A. Schizophrenia.
- B. Panic disorder.
- C. Depression.
- D. Delirium.
Correct Answer: D
Rationale: Disheveled appearance, emotional lability, inappropriate responses, and physical symptoms (tachycardia, tachypnea, clammy skin) suggest delirium, a medical emergency requiring urgent assessment.
A client treated for hypertension with furosemide (Lasix), atenolol (Tenormin), and ramipril (Altace) develops a second degree heart block Mobitz type 1. Which of the following actions should the nurse take?
- A. Administer a 250 mL fluid bolus.
- B. Withhold the atenolol.
- C. Prepare for cardioversion.
- D. Set up for an arterial line.
Correct Answer: B
Rationale: Atenolol, a beta-blocker, can exacerbate heart block by slowing conduction. Withholding it and consulting the physician is the priority.