Nokea
The nurse is providing care to a 75-year-old female patient diagnosed with osteoporosis. Which of the following would be the priority nursing diagnosis?
- A. At risk for falls related to impaired balance
- B. Knowledge deficit related to new medication regimen
- C. Impaired physical mobility related to pain and skeletal changes
- D. Ineffective health maintenance related to continued immobility
Correct Answer: A
Rationale: The correct answer is A: At risk for falls related to impaired balance. This is the priority nursing diagnosis because falls can lead to serious injury in elderly patients with osteoporosis. Impaired balance is a significant risk factor for falls in this population. Choice B is not the priority as safety takes precedence over knowledge deficit. Choice C may be secondary to the risk of falls. Choice D is not the priority as preventing falls and ensuring patient safety are more critical in this case.
You may also like to solve these questions
Expectant parents ask a prenaNtal RnursIe eGducaBto.rC, “WMhich setting for childbirth limits the U S N T O amount of parent–infant interaction?” Which answer should the nurse provide for these parents in order to assist them in choosing an appropriate birth setting?
- A. Birth center
- B. Home birth
- C. Traditional hospital birth
- D. Labor, birth, and recovery room
Correct Answer: C
Rationale: Rationale:
1. Traditional hospital birth setting often involves medical interventions that can limit parent-infant interaction, such as continuous fetal monitoring and medication administration.
2. These interventions may restrict movement and bonding opportunities between the parent and infant during labor and immediately after birth.
3. In contrast, birth center and home birth settings typically prioritize natural childbirth experiences with minimal interventions to encourage bonding and parent-infant interaction.
4. Labor, birth, and recovery room, while providing a more private setting than a traditional hospital, may still involve medical interventions that can impact parent-infant interaction.
Summary:
A: Birth center and B: Home birth promote parent-infant interaction. D: Labor, birth, and recovery room may still involve interventions. C: Traditional hospital birth setting often limits parent-infant interaction due to medical interventions.
Fibrocystic changes in the breast most often appear in women in their 20s and 30s. Although the cause is unknown, an imbalance of estrogen and progesterone may be the cause. The nurse who cares for this client should be aware that treatment modalities are conservative. Which proven modality may offer relief for this condition?
- A. Diuretic administration
- B. Daily inclusion of caffeine in the diet
- C. Increased vitamin C supplementation
- D. Application of cold packs to the breast as necessary
Correct Answer: A
Rationale: Diuretics and a decrease in sodium intake can provide relief for fibrocystic breast changes. The use of caffeine is not recommended, and vitamin E should be taken in moderation.
The nurse is assessing a 25-year-old female patient when the patient becomes tearful. The patient states that she has thin milky discharge from her nipples and two small masses on her left breast. She has lost over 40 pounds in the past year due to intensive exercises and finds that she needs to wear a sports bra during her sessions. The patient states that she is afraid that she will become the first member of her family to have breast cancer. Besides a negative mammogram, what other symptoms would correlate with this being a benign finding? Select all that apply.
- A. Milky discharge from nipples
- B. Extensive weight loss
- C. Painful masses
- D. Mood swings
Correct Answer: A
Rationale: The correct answer is A: Milky discharge from nipples. Milky discharge from nipples in a young female with no other concerning symptoms can be indicative of benign conditions such as hormonal imbalances or medication side effects. In this case, the patient's age, weight loss due to exercise, and negative mammogram are all factors that suggest a low likelihood of breast cancer. Extensive weight loss (choice B) is likely attributed to the intensive exercises mentioned and not directly correlated with breast cancer. Painful masses (choice C) could indicate an inflammatory or infection process but are not necessarily indicative of malignancy. Mood swings (choice D) are unrelated to the breast symptomatology described.
Which statement regarding the Family Systems Theory is inaccurate?
- A. Family system is part of a larger suprasystem.
- B. Family, as a whole, is equal to the sum of the individual members.
- C. Changes in one family member affect all family members.
- D. Family is able to create a balance between change and stability.
Correct Answer: B
Rationale: Family Systems Theory posits that the family as a whole is greater than the sum of its individual members, meaning the family's dynamics are more complex than just the sum of each individual. The other statements are accurate according to this theory.
The nurse states to the newly pregnant patient, “Tell me how you feel about being pregnant.” Which communication technique is the nurse using with this patient?
- A. Clarifying
- B. Paraphrasing
- C. Reflection
- D. Structuring
Correct Answer: C
Rationale: The correct answer is C: Reflection. The nurse is using a reflection communication technique by restating the patient's feelings to show understanding and empathy. This helps the patient feel heard and validated. Clarifying (A) involves seeking more information, paraphrasing (B) involves restating the patient's words, and structuring (D) involves providing organization or direction. In this scenario, the nurse is not seeking more details (Clarifying), restating the patient's words exactly (Paraphrasing), or providing organization/direction (Structuring), but rather reflecting the patient's emotions back to them.