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What is the most appropriate nursing diagnosis for this patient?
- A. Self-esteem disturbance related to late diagnosis
- B. Ineffective individual coping related to reluctance to seek care
- C. Altered family process related to inability to obtain treatment
- D. Ineffective denial related to reluctance to seek care
Correct Answer: B
Rationale: Ineffective individual coping is the inability to assess our own stressors and then make choices to access appropriate resources. In this case, the patient was unable to access health care even when she was aware the disorder could be life-threatening. Self-esteem Disturbance, Altered Family Process, and Ineffective Denial are all nursing diagnoses that are often associated with breast cancer, but the patients ineffective individual coping has created a significant safety risk and is, therefore, the most appropriate nursing diagnosis.
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What would be the most appropriate nursing intervention?
- A. Put the primary onus for planning care on the patient herself.
- B. Assess and provide constructive outlets for anger and hostility.
- C. Assess the patients sources of social support.
- D. Encourage an attitude of realistic hope to help her deal with helpless feelings.
Correct Answer: D
Rationale: By encouraging an attitude of realistic hope, the patient will be empowered. This allows the patient to explore her feelings and bring about more effective coping patterns. The onus for care planning should not lie with the patient. The nursing diagnosis is related to feeling of helplessness, not anger and hostility. Social support is necessary, but does not directly address the feeling of helplessness.
You should be aware that the oxygen demands of the patients body would change in which direction and why?
- A. Increase due to an increase in metabolism
- B. Decrease due to a decrease in metabolism
- C. Increase due to a decrease in metabolism
- D. Decrease due to an increase in metabolism
Correct Answer: A
Rationale: When a persons temperature is elevated, hypermetabolism occurs, and the respiratory rate, heart rate, and basal metabolic rate increase. The other options are incorrect because oxygen demands would not decrease and they would not increase due to a decrease in metabolism.
What positive outcome of providing the patient with information should the nurse expect?
- A. Increased concentration
- B. Decreased depression levels
- C. Sharing of personal details
- D. Building interdependent relationships
Correct Answer: A
Rationale: Giving patients information also reduces the emotional response so that they can concentrate and solve problems more effectively. Educating the patient does not decrease depression levels or build interpersonal relationships. Educating the patient does not mean sharing of personal details.
What would be your best response?
- A. This is a local inflammatory response to the insect bite; it is not an infection so antibiotics will not help.
- B. In children who are previously healthy, inflammation and infections usually resolve without the need for drugs.
- C. Ill make sure the doctor is made aware that youd like your son to have a course of antibiotics.
- D. Infection is not the same as inflammation. What your son has is inflammation.
Correct Answer: A
Rationale: Regardless of the cause, a general sequence of events occurs in the local inflammatory response. This sequence involves changes in the microcirculation, including vasodilation, increased vascular permeability, and leukocytic cellular infiltration. As these changes take place, five cardinal signs of inflammation are produced: redness, heat, swelling, pain, and loss of function. Infections do not always resolve spontaneously. The nurse should teach the patients father about the reasons that antibiotics are unnecessary rather than simply deferring to the physician.
How should you best respond if it is found that the patients health patterns are not achieving their goals?
- A. Seek ways to promote balance in the patient.
- B. Refer the patient to social work.
- C. Identify alternative models of health care.
- D. Provide insight into the patients physiological failings.
Correct Answer: A
Rationale: The nurse has a significant role and responsibility in identifying the health patterns of the patient receiving care. If those patterns are not achieving physiologic, psychological, and social balance, the nurse is obligated, with the assistance and agreement of the patient, to seek ways to promote balance. The nurse is not obligated to refer to social work, identify alternative forms of care, or provide insight into the physiologic failings of the system if the patients health patterns are not achieving their goals.