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When planning care for a 16-year-old with appendicitis presenting with right lower quadrant pain, what should the nurse prioritize as a nursing diagnosis?
- A. Imbalanced nutrition: Less than body requirements related to decreased oral intake
- B. Risk for infection related to possible rupture of the appendix
- C. Constipation related to decreased bowel motility and decreased fluid intake
- D. Chronic pain related to appendicitis
Correct Answer: B
Rationale: The correct answer is B: Risk for infection related to possible rupture of the appendix. This is the priority nursing diagnosis because appendicitis can lead to a life-threatening condition if the appendix ruptures. The nurse needs to monitor for signs of worsening infection such as fever and increased pain.
A: Imbalanced nutrition is not the priority as it is secondary to the risk of infection.
C: Constipation is not the priority as it is not directly related to the life-threatening complication of appendicitis.
D: Chronic pain is also not the priority as the risk of infection and potential rupture take precedence in the care of the patient.
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A 45-year-old obese man arrives at a clinic reporting daytime sleepiness, difficulty falling asleep at night, and snoring. The nurse should recognize the manifestations of what health problem?
- A. Adenoiditis
- B. Chronic tonsillitis
- C. Obstructive sleep apnea
- D. Laryngeal cancer
Correct Answer: C
Rationale: The correct answer is C: Obstructive sleep apnea. The patient's symptoms of daytime sleepiness, difficulty falling asleep, and snoring are classic signs of obstructive sleep apnea, a condition where the upper airway collapses during sleep, leading to pauses in breathing. This results in poor sleep quality and daytime fatigue. Adenoiditis (choice A) and chronic tonsillitis (choice B) typically present with symptoms like sore throat and difficulty swallowing, which are not seen in this patient. Laryngeal cancer (choice D) would present with hoarseness, persistent cough, and difficulty swallowing, which are not mentioned in the patient's symptoms. Therefore, based on the patient's presentation, the most likely diagnosis is obstructive sleep apnea.
A 70-year-old man presents with weight loss, jaundice, and a palpable mass in the right upper quadrant. Laboratory tests reveal elevated bilirubin and alkaline phosphatase levels. What is the most likely diagnosis?
- A. Gallstones
- B. Hepatitis
- C. Pancreatic cancer
- D. Primary biliary cirrhosis
Correct Answer: C
Rationale: The most likely diagnosis in this case is pancreatic cancer (Choice C) based on the constellation of symptoms including weight loss, jaundice, palpable mass in the right upper quadrant, and elevated bilirubin and alkaline phosphatase levels. These findings are indicative of a pancreatic head mass causing obstruction of the common bile duct, leading to jaundice and elevated liver enzymes. Gallstones (Choice A) typically present with colicky pain, not a palpable mass. Hepatitis (Choice B) would present with different liver enzyme patterns and usually lacks a palpable mass. Primary biliary cirrhosis (Choice D) typically presents with pruritus and fatigue, not a palpable mass and jaundice.
A client with a history of chronic alcohol abuse is at risk for which of the following conditions?
- A. Liver cirrhosis
- B. Renal failure
- C. Chronic obstructive pulmonary disease (COPD)
- D. Peptic ulcer disease
Correct Answer: A
Rationale: The correct answer is A: Liver cirrhosis. Chronic alcohol abuse is a leading cause of liver cirrhosis due to the toxic effects of alcohol on the liver over time. Alcohol metabolism leads to liver inflammation, scarring, and ultimately cirrhosis. Renal failure (B) is not directly linked to alcohol abuse but can occur in severe cases. COPD (C) is primarily caused by smoking, not alcohol abuse. Peptic ulcer disease (D) can be exacerbated by alcohol but is not directly caused by chronic alcohol abuse. Therefore, the most significant risk for a client with a history of chronic alcohol abuse is developing liver cirrhosis.
The nurse has completed the admission assessment of a client and has determined that the client's body mass index (BMI) is 33.5 kg/m2. What health promotion advice should the nurse provide to the client?
- A. It would be very helpful if you could integrate more physical activity into your routine.
- B. You're considered to be overweight, so you should be diligent about maintaining a healthy diet.
- C. You might want to consider some of the surgical options that have been developed for treating obesity.
- D. With your permission, I'd like you to refer to a support group for individuals who live with severe obesity.
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer (A):
1. BMI of 33.5 indicates the client is in the overweight category.
2. Physical activity can help in weight management and improving overall health.
3. Integrating physical activity can help in reducing weight and lowering BMI.
4. Health promotion advice should focus on lifestyle changes rather than surgical interventions or support groups.
Summary of why other choices are incorrect:
B: While maintaining a healthy diet is important, focusing solely on diet may not be as effective as incorporating physical activity for weight management.
C: Surgical options are typically considered for severe obesity cases, which may not be necessary at a BMI of 33.5.
D: Referring to a support group for severe obesity may not be appropriate at this stage as lifestyle modifications should be the initial approach.
A client is being treated with an antidepressant for major depressive disorder. Which statement by the client indicates a need for further teaching?
- A. I know it may take several weeks before I start feeling better.
- B. I should avoid drinking alcohol while taking this medication.
- C. I will stop taking the medication as soon as I feel better.
- D. I should take the medication at the same time every day.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Stopping medication abruptly can lead to withdrawal symptoms and a potential relapse of depressive symptoms.
2. The client should be educated on the importance of completing the full course of treatment.
3. This statement indicates a lack of understanding regarding the need for continued medication adherence.
4. Choices A, B, and D are all appropriate and demonstrate good understanding of antidepressant treatment.