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?

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.

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.

Correct Answer: B

Rationale: The correct answer is B: Resolve the client’s anxiety. Addressing the client's anxiety is the priority because it can impact their overall surgical experience, recovery, and outcomes. Resolving anxiety can improve the client's emotional well-being, enhance cooperation during surgery, and reduce postoperative complications related to stress. Providing emotional support and reassurance should be the initial focus to help the client feel more comfortable and confident about the upcoming surgery. The other choices are not the priority in this situation: A) Evaluating the need for antibiotics can be addressed later in the preoperative process, C) Providing preoperative education is important but not the immediate priority over addressing anxiety, and D) Preparing the client for surgery includes various components, but emotional well-being should be addressed first.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by identifying the patient's main issue or reason for seeking care. This step helps prioritize data collection and guides further assessment and intervention. By focusing on the presenting situation, the nurse can gather relevant information efficiently and address the immediate concern. Incorrect choices: A: Completing questions in chronological order may not be the most effective approach as it does not prioritize the patient's current problem. C: Making accurate interpretations of data comes after data collection and analysis, not as the first step. D: Conducting an observational overview is important, but it should come after focusing on the patient's presenting situation to gather targeted data.

Correct Answer: B

Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance. A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention. C: Thyroid hormone does not directly influence sodium retention. D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.

Correct Answer: B

Rationale: The correct answer is B: Use two people to assist the patient. This is the safest option as it provides optimal support and stability for the patient during their first postoperative ambulation. Two people can help prevent falls, ensure proper body mechanics, and offer immediate assistance if needed. Using one person (choice A) may not provide enough support. Encouraging the patient to "dangle" (choice C) may increase the risk of orthostatic hypotension. Giving a narcotic before ambulation (choice D) can impair the patient's balance and coordination, increasing the risk of falls.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care. Incorrect choices: A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.

Correct Answer: D

Rationale: The correct answer is D: “Your heart is not an efficient pump.” This response is the best choice as it accurately describes heart failure, which is a condition where the heart is unable to pump blood effectively. This leads to symptoms such as fatigue, shortness of breath, and fluid retention. Explanation: 1. Choice A is incorrect because heart failure does not mean the heart stops; it means the heart is not functioning properly. 2. Choice B is incorrect because heart failure does not necessarily mean there is dead muscle tissue in the heart. 3. Choice C is incorrect because heart failure is not about pumping too much blood; it is about the heart's inability to pump blood efficiently, leading to circulation problems and other symptoms.

Correct Answer: A

Rationale: The correct answer is A: It inhibits deoxyribonucleic acid (DNA) synthesis. Mitomycin works by cross-linking DNA, leading to inhibition of DNA synthesis and ultimately causing cell death. This mechanism of action makes it effective against rapidly dividing cancer cells. B: It’s cell cycle-phase specific - This is incorrect because mitomycin is not specific to a particular phase of the cell cycle. C: It inhibits ribonucleic acid (RNA) synthesis - This is incorrect as mitomycin primarily targets DNA synthesis, not RNA synthesis. D: It inhibits protein synthesis - This is incorrect as mitomycin's main mechanism of action is through DNA cross-linking, not protein synthesis inhibition.