A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:

Correct Answer: C

Rationale: The correct answer is C: fluid volume deficit. In diabetes insipidus, there is an excessive amount of dilute urine excreted, leading to dehydration and fluid volume deficit. The posterior pituitary tumor causes a deficiency in antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys. As a result, the client experiences polyuria and polydipsia, leading to fluid volume deficit. Choices A, B, and D are incorrect because diabetes insipidus does not cause fluid volume excess, incontinence, or diarrhea. The key is to recognize the pathophysiology of diabetes insipidus and its impact on fluid balance.

Correct Answer: A

Rationale: The correct initial action for the nurse to take is A: Try to have the client breathe slower. This is because the client may be experiencing respiratory distress, and slowing down their breathing can help improve oxygenation. Giving O2 via nasal cannula (B) should be considered if the client's oxygen saturation is low after trying to slow down their breathing. Administering sodium bicarbonate (C) is not the appropriate initial action unless the client is experiencing severe acidosis. Monitoring the client's fluid balance (D) is important but not the best initial action in this scenario where respiratory distress is the concern.

Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is highly indicative of breast cancer. This finding suggests an invasive tumor pulling on the skin, causing dimpling. Other choices are incorrect because slight breast asymmetry (A) is common, bloody nipple discharge (C) can be benign or due to other conditions, and multiple freely movable masses (D) are more indicative of benign breast conditions like fibrocystic changes.

Correct Answer: B

Rationale: The correct answer is B because monitoring the site and progress of the infusion every hour is crucial to prevent complications like infiltration or infection in clients with hypertension. Choice A is incorrect as checking BP every hour is excessive. Choice C is incorrect as daily monitoring may not detect issues promptly. Choice D is incorrect as pulse rate monitoring is not directly related to IV fluid administration in this context. Monitoring the site and progress hourly ensures timely intervention if any issues arise.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently. A: Completing questions in chronological order may not address the current problem effectively. C: Making accurate interpretations of the data comes after data collection, not as the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.

Correct Answer: C

Rationale: The correct answer is C: Autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their own healthcare. In this scenario, the client is expressing her desire to not undergo surgery, which is her right as an autonomous individual. The nurse must respect her decision even if it goes against medical advice. Beneficence (A) is the ethical principle of doing good for the patient, but in this case, respecting the client's autonomy takes precedence. Advocacy (B) involves supporting the client's best interests, which could align with autonomy in this case. Justice (D) refers to fairness and equal treatment, but it is not directly applicable to the client's decision regarding surgery.

Correct Answer: C

Rationale: The correct answer is C: Lean red meats. Lean red meats are a rich source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Heme iron helps improve iron levels more effectively in individuals with iron deficiency anemia. Fresh fruits (A) and dairy products (B) contain minimal iron, while breads and cereals (D) provide non-heme iron which is not as readily absorbed.

Correct Answer: A

Rationale: The correct answer is A: Pneumocystis carinii pneumonia (PCP). PCP is the most common opportunistic infection in AIDS due to the weakened immune system, making patients vulnerable to this fungal infection. PCP is a leading cause of morbidity and mortality in AIDS patients. Toxoplasmosis (B) is also common but not as prevalent as PCP in AIDS. Candidiasis (C) is a common fungal infection but not the most common in AIDS. Mycoplasma pneumoniae (D) is a bacterial infection and not typically considered an opportunistic infection in AIDS.

Correct Answer: A

Rationale: Rationale: A: Pressing the system in place for 30 to 60 seconds helps ensure proper adhesion and absorption of the medication. This step is crucial for the effectiveness of the pain management system. B: Choosing a site on the lower torso is not necessary for applying the system. The site selection should be based on guidelines and patient preference. C: Shaving the application site is not recommended unless specifically indicated. It is not a standard step for applying a pain management system. D: Applying the system immediately after removal from a package may not allow the adhesive to fully activate, affecting its efficacy. It is important to follow the recommended steps for proper application.