A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Correct Answer: B

Rationale: A client with a cerebellar brain tumor is likely to experience impaired balance due to the location of the tumor affecting the cerebellum, which is responsible for coordinating movement and balance. Impaired balance increases the risk for falls and other injuries, making it a priority concern for the client. Therefore, adding "Related to impaired balance" to the nursing diagnosis statement would be the most appropriate choice to address the client's risk for injury in this situation.

Correct Answer: D

Rationale: Breast self-examination (BSE) is a very popular means of early detection of breast cancer as it involves women being aware of how their breasts look and feel to detect any changes such as lumps, swelling, or other abnormalities. By performing regular self-examinations, women can identify any potential issues early on and seek medical advice promptly. While mammograms (X-ray) and clinical breast exams by healthcare providers are also important screening methods for detecting breast cancer, BSE is particularly valuable as women can perform it on a regular basis at home, thus increasing the chances of identifying any concerning changes promptly. It is recommended that women perform BSE monthly to become familiar with their breast tissue and notice any changes over time.

Correct Answer: C

Rationale: Early postoperative ambulation is important for preventing complications such as pneumonia. When a patient remains immobile for an extended period after surgery, they are at an increased risk of developing pneumonia due to decreased lung expansion and secretions pooling in the lungs. Ambulation helps improve lung function, promote better oxygenation, and prevent respiratory complications like pneumonia. In contrast, increased peristalsis helps prevent constipation, coughing helps prevent respiratory complications as well, and wound healing is not directly related to the need for early postoperative ambulation.

Correct Answer: B

Rationale: Fatigue in a patient with heart failure is commonly caused by decreased cardiac output. In heart failure, the heart is unable to pump enough blood to meet the body's demands, resulting in reduced delivery of oxygen and nutrients to the tissues. This can lead to generalized weakness and fatigue. Dyspnea (choice A) is commonly associated with heart failure but is more specific to difficulty breathing, while a dry cough (choice C) is a symptom that can be present but is not typically the primary cause of fatigue. Orthopnea (choice D) is a symptom of heart failure characterized by difficulty breathing when lying flat but is not directly related to the patient's increasing fatigue in this scenario.

Correct Answer: A

Rationale: In the context of pediatric pharmacology and care after heart transplantation, it is crucial for nurses to understand the signs of organ rejection. The correct answer, "A) Low white blood cell count," is a key indicator of organ rejection in a post-transplant patient. A decrease in white blood cells may signify the body's immune response attacking the transplanted organ, leading to rejection. Dyspnea (B), ECG changes (C), and fever (D) are common symptoms in various clinical scenarios but are not specific to organ rejection after a heart transplant. Dyspnea can occur due to various reasons including heart failure or respiratory issues post-surgery. ECG changes can occur due to electrolyte imbalances or surgical stress. Fever can be a sign of infection, inflammation, or other post-operative complications. Educationally, it is important for nurses to recognize the unique signs and symptoms of organ rejection in pediatric patients after heart transplantation to ensure timely intervention and prevent complications. Understanding these specific indicators helps in early detection and management of rejection episodes, ultimately improving patient outcomes and quality of life. Nurses play a critical role in post-transplant care by monitoring closely for signs of rejection and collaborating with the healthcare team for appropriate interventions.