A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling make his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?

Correct Answer: B

Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being. Rationale: 1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move. 2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg. 3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Assessment of neurologic signs establishes baseline for post-op care. 2. Helps detect any changes post-surgery. 3. Enables prompt intervention if any issues arise. 4. Planning activities (B) is not a priority pre-surgery. 5. Enema (C) may not be necessary for all surgeries. 6. Explaining complications (D) is important but not a primary pre-op nursing care.

Correct Answer: C

Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.

Correct Answer: A

Rationale: The correct answer is A: Basophils. Basophils are a type of white blood cell that release histamine during allergic reactions. They contain granules filled with histamine, which is released when they encounter an allergen. Monocytes, eosinophils, and neutrophils do not release histamine during allergic reactions. Monocytes are involved in immune response and inflammation, eosinophils are responsible for combating parasitic infections, and neutrophils are primarily involved in fighting bacterial infections.

Correct Answer: B

Rationale: The correct answer is B because optimum sleep helps regulate breathing patterns during an EEG. Waking the client at midnight allows them to have a full night's rest, ensuring they are well-rested and their breathing is stable for accurate EEG results. Choice A is incorrect as excess sleep does not affect nervousness. Choice C is incorrect as waking the client does not help them fall asleep naturally during the EEG. Choice D is incorrect as headache prevention is not directly related to waking the client at midnight.

Correct Answer: A

Rationale: The correct answer is A: The client’s breathing will become easier. Epinephrine is the first-line treatment for anaphylaxis as it helps to reverse the severe respiratory symptoms. By administering epinephrine, it causes bronchodilation, which helps improve breathing by opening up the airways. Choices B, C, and D are incorrect. B is incorrect because epinephrine typically causes an increase in blood pressure due to its vasoconstrictive effects. C is incorrect because angioedema is a potential side effect of anaphylaxis and would not be expected to increase after epinephrine administration. D is incorrect because epinephrine helps to improve alertness and consciousness by increasing blood flow to the brain.

Correct Answer: C

Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis. A: Hyperventilation would lead to respiratory alkalosis, not acidosis. B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis. D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis. In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.

Correct Answer: B

Rationale: The correct answer is B: Increased urine osmolarity. In hyperglycemia, the body tries to eliminate excess glucose through increased urine output, causing a concentrated urine with high osmolarity. This indicates fluid deficit. Cool, clammy skin (A) may suggest poor perfusion but not fluid volume deficit. Distended neck veins (C) are more indicative of fluid overload. Serum sodium level (D) may be elevated in fluid deficit but does not directly assess volume status like urine osmolarity does.

Correct Answer: A

Rationale: The correct answer is A: Painless hematuria. This is an early indicator of bladder cancer because blood in the urine without pain is a common symptom in the early stages of the disease. Nocturia (B), frequent urination at night, is more commonly associated with urinary tract infections or benign prostatic hyperplasia. Occasional polyuria (C), excessive urination, can be a symptom of diabetes or kidney disease. Dysuria (D), painful urination, is more indicative of urinary tract infections or urethritis. Therefore, painless hematuria is the most specific early indicator of bladder cancer among the choices provided.