Nokea
Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?
- A. The client verbalizes knowledge of a maintenance diet.
- B. The client demonstrates assertiveness with family.
- C. The client verbalizes her body size accurately.
- D. The client demonstrates control of obsessive behaviors.
Correct Answer: C
Rationale: Part of the problem for anorexic clients is an altered view of their body appearance (visualizing themselves as fat even when they are emaciated). Knowledge of a maintenance diet involves a knowledge deficit. Assertiveness with family involves possible resolution of family-dynamic issues. Control of obsessive behaviors involves psychological adaptation.
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The client with diarrhea has had four bowel movements in the past eight hours, measuring 150 mL, 100 mL, 100 mL and 150 mL. The client is to receive one-to-one replacement with a bolus of IV 0.9% NaCl to be infused over the next two hours. How many mL of 0.9% NaCl will the nurse infuse each hour?
Correct Answer: 250
Rationale: Total loss is 500 mL (150+100+100+150). One-to-one replacement means 500 mL over 2 hours, so 500/ 2 = 250 mL per hour.
Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophageal reflux disease (GERD)?
- A. lettuce
- B. eggs
- C. chocolate
- D. butterscotch
Correct Answer: C
Rationale: Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. The other foods do not affect LES pressure.
Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
- A. Sleep Pattern Disturbances (related to arthritis)
- B. Fatigue (related to leg pain)
- C. Knowledge Deficit (regarding sleep hygiene measures)
- D. Sleep Pattern Disturbances (related to chronic leg pain)
Correct Answer: D
Rationale: The client's sleep pattern is directly disturbed by the chronic leg pain, which is secondary to the arthritis. This nursing diagnosis is the appropriate one to directly deal with comfort measures and the like.
In evaluating the lab work of a client in a hepatic coma, which of the following lab tests is most important?
- A. Blood urea nitrogen
- B. Serum calcium
- C. Serum ammonia
- D. Serum creatinine
Correct Answer: C
Rationale: Elevated serum ammonia is critical in hepatic coma, as liver failure impairs ammonia metabolism, causing brain-tissue irritation.
Which of the following individuals may legally give informed consent?
- A. an 86-year-old male with advanced Alzheimer's disease
- B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- C. a 72-year-old female scheduled for a heart transplant
- D. a 6-month-old baby needing bowel surgery
Correct Answer: C
Rationale: Only competent adults can legally give informed consent. The 72-year-old female is presumed competent unless stated otherwise. An individual with advanced Alzheimer's lacks decision-making capacity, a non-emancipated minor cannot consent, and infants are legally incapable of consenting; their guardians must provide consent.