Nokea
The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
- A. When I get stressed out about school, I just like to be alone.
- B. I find myself very moody. I'm happy one minute and crying the next.
- C. I don't eat any fatty foods, and I've already lost 8 pounds in 2 weeks.
- D. I can't seem to wake up in the morning. I would sleep until noon if I could.
Correct Answer: C
Rationale: During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and losing weight during a time of growth suggests inadequate nutrition and a possible eating disorder. The remaining options are normal behaviors or feelings that occur during adolescence.
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A teenager diagnosed with celiac disease arrives at the emergency department reporting profuse, watery diarrhea after a pizza party the night before. The client states, 'I don't want to be different from my friends.' Which acute client concern should the nurse focus on when responding to the client?
- A. Diarrhea
- B. Low self-esteem
- C. Deficient fluid volume
- D. Increased inflammation
Correct Answer: B
Rationale: The client expresses concern about being different from friends. Celiac crisis is a medical diagnosis that often involves diarrhea. Although the question states that the client has profuse, watery diarrhea, no data identify an actual deficient fluid volume or increased inflammation.
A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The parents ask questions about the condition. The nurse should respond to the parents that which condition can occur and have a psychosocial impact if the undescended testicle is not corrected?
- A. Atrophy
- B. Infertility
- C. Malignancy
- D. Feminization
Correct Answer: B
Rationale: Infertility can occur in males with this condition because proper function of the testes in producing fertile sperm depends on a temperature of less than 98.6°F (37.0°C). The psychological effects of an 'empty scrotum' could affect the client's perception of self and the ability to reproduce. Options 1 and 3 are possible physical consequences of a failure to treat cryptorchidism rather than psychosocial consequences. Because all of the hormones that are responsible for secondary sex characteristics continue to be secreted directly into the bloodstream, option 4 is not correct.
A pregnant client is newly diagnosed with gestational diabetes. The client cries when receiving this information and keeps repeating, 'What have I done to cause this? If only I could live my life over.' Considering this statement, which concern should the nurse identify for the client?
- A. Injury to the fetus because of maternal distress
- B. Low self-esteem because of pregnancy complications
- C. Lack of understanding about diabetic self-care during pregnancy
- D. Poorly perceived body image caused by complications of pregnancy
Correct Answer: B
Rationale: The client is putting the blame for the diabetes on herself, thus lowering her self-esteem. She is expressing fear and grief. There are no data in the question to support the problems in options 1 and 4. Client lack of understanding is important to consider, but not at this time because the client will not be able to comprehend information in her current state.
The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe?
- A. The client is experiencing delusions of messianic grandeur.
- B. The client believes that the world is ending on a specific date.
- C. The client is experiencing persistent pain after the resolution of herpes zoster.
- D. The client is experiencing blindness without an identified physical cause.
Correct Answer: D
Rationale: Conversion disorder involves physical symptoms, like blindness, without a medical cause, often linked to psychological stress. Blindness without a physical cause is a classic example, unlike delusions or unrelated pain.
When planning the care of the client diagnosed with thromboangiitis obliterans (Buerger's disease), the nurse incorporates information on which support service to best help the client cope with the lifestyle changes that are needed to control the disease process?
- A. Consult with a dietician
- B. Pain management clinic
- C. Smoking cessation program
- D. Referral to a medical social worker
Correct Answer: C
Rationale: Smoking is highly detrimental to the client with Buerger's disease, and clients are recommended to stop completely. Because smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients, symptoms are relieved or alleviated when smoking stops. None of the remaining options are directly related to the physiology associated with this condition.