Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
- A. "What would you like to do first, brush your teeth?"
- B. "Where is y our toothbrush?"
- C. "When would you like to have your bath?"
- D. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
Correct Answer: D
Rationale: Rationale:
- Choice D is correct as it offers the patient autonomy and promotes self-care, which is important for maintaining independence and dignity.
- By giving the patient a choice between brushing their own teeth or having assistance, it empowers them to make decisions.
- Choices A, B, and C are not as appropriate because they do not address the patient's autonomy and may come across as directive or intrusive, which can further exacerbate the altered thought process.
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A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?
- A. Anticipatory grieving
- B. Disturbed body image
- C. Impaired swallowing
- D. Chronic low self-esteem
Correct Answer: A
Rationale: The correct answer is A: Anticipatory grieving. This nursing diagnosis is appropriate because the client's symptoms, such as weight loss, fatigue, and diagnosis of gallbladder cancer, indicate a serious health condition that may lead to emotional distress. Anticipatory grieving involves feelings of loss and sadness related to an anticipated loss, such as the diagnosis of cancer. The client may experience fear, anxiety, and sadness due to the potential impact of the illness on their life.
Choice B (Disturbed body image) is incorrect because the client's symptoms are more indicative of a serious health concern rather than body image issues. Choice C (Impaired swallowing) is incorrect as the symptoms described do not suggest difficulty with swallowing. Choice D (Chronic low self-esteem) is also incorrect as the symptoms are more likely related to physical health issues rather than self-esteem concerns.
The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body’s normal flora, the nurse must monitor the client for:
- A. Platelet dysfunction
- B. Stomatitis
- C. Oliguria and dysuria
- D. Diarrhea
Correct Answer: D
Rationale: The correct answer is D: Diarrhea. Antibiotics can disrupt the normal balance of gut bacteria, leading to diarrhea. This occurs due to the overgrowth of harmful bacteria in the intestines. Monitoring for diarrhea is crucial to prevent dehydration and further complications. Platelet dysfunction (A), stomatitis (B), and oliguria/dysuria (C) are not typically associated with the disruption of normal flora by antibiotics. These symptoms are more likely related to other conditions or side effects of medications, making them incorrect choices in this scenario.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?
- A. Cerebral edema
- B. Severe hyperkalemia
- C. Hypovolemic shock
- D. Tetany
Correct Answer: A
Rationale: Correct Answer: A - Cerebral edema
Rationale:
1. SIADH leads to water retention and dilutional hyponatremia.
2. Diuretic therapy aims to increase urine output and correct fluid imbalance.
3. If the client does not comply, excessive water retention can lead to cerebral edema.
4. Cerebral edema is a serious complication that can cause neurological deficits.
Summary:
- B: Severe hyperkalemia is unlikely as diuretics would help excrete excess potassium.
- C: Hypovolemic shock is not expected as fluid restriction may prevent rapid volume loss.
- D: Tetany is not a direct consequence of non-compliance with treatment for SIADH.
The knows that a positive diagnosis for HIV infection is made based on; a.A history of high-risk sexual behaviors
- A. Positive ELISA and Western blot tests
- B. Evidence of extreme weight loss and high fever
- C. Identification of an associated opportunistic infection
Correct Answer: A
Rationale: The correct answer is A because a positive diagnosis for HIV infection is confirmed through laboratory testing, specifically the ELISA and Western blot tests. These tests detect the presence of HIV antibodies in the blood, providing definitive evidence of the infection. Choice B is incorrect as weight loss and fever are symptoms but not diagnostic criteria. Choice C is incorrect as opportunistic infections are a consequence of HIV, not the diagnostic criteria. Choice D is incomplete and irrelevant. In summary, the key to diagnosing HIV is through positive laboratory tests, not just based on symptoms or associated infections.
The clinical manifestations of Parkinson’s disease (bradykinesia rigidity and tremors) is directly related to a decreased level of:
- A. Acetylcholine
- B. Serotonin
- C. Dopamine
- D. Phenylalanine
Correct Answer: C
Rationale: Rationale: Parkinson's disease is characterized by dopamine deficiency in the brain, leading to motor symptoms like bradykinesia, rigidity, and tremors. Dopamine is crucial for controlling movement. Acetylcholine (A) is not directly related to Parkinson's symptoms. Serotonin (B) is involved in mood regulation, not movement control. Phenylalanine (D) is an amino acid and not directly related to Parkinson's pathology. Therefore, the correct answer is C.