A female patient with chronic skin lesions of the face and arms tells the nurse that she cannot stand to look at herself in the mirror anymore because of her appearance. Based on this information, the nurse identifies which nursing diagnosis?

Correct Answer: B

Rationale: The correct nursing diagnosis in this scenario is option B) Disturbed body image related to perception of unsightly lesions. This is because the patient's statement directly indicates a negative impact on her self-perception due to the skin lesions. The patient's inability to look at herself in the mirror signifies a disturbance in her body image perception. Option A) Anxiety related to personal appearance is incorrect as the patient's issue is more focused on body image perception rather than generalized anxiety about personal appearance. Option C) Social isolation related to decreased activities as a result of poor self-image is incorrect because there is no information provided about the patient withdrawing from social activities. The focus is on the patient's self-perception. Option D) Ineffective self-health management related to lack of knowledge of cover-up techniques is incorrect as it does not address the emotional and psychological impact of the skin lesions on the patient's body image. Educationally, understanding how to accurately identify nursing diagnoses based on patient data is crucial for providing effective care. By selecting the correct nursing diagnosis, nurses can tailor interventions to address the specific needs and concerns of the patient, ultimately leading to improved outcomes and patient satisfaction. It is essential for nurses to have a strong foundation in nursing diagnosis to provide holistic care addressing both physical and emotional aspects of health.

Correct Answer: C

Rationale: The correct answer is C) Saline. Using saline to clean a wound is recommended because it is a gentle and effective way to remove debris and bacteria without damaging the surrounding tissues or causing further irritation. Saline solution is isotonic, meaning it has a similar concentration of salt and minerals as the body, which helps to promote healing and reduce the risk of infection. Option A) Hydrogen peroxide is not recommended for cleaning wounds as it can be too harsh on the tissues, leading to delayed wound healing and potential damage to healthy cells. The bubbling action can also disrupt the wound bed and impede the healing process. Option B) Tap water may contain impurities or chemicals that can be harmful if introduced into an open wound. It is not sterile like saline solution, which increases the risk of infection. Option D) Leaving a wound undisturbed can be appropriate in some cases, but it is essential to clean a wound to prevent infection and promote proper healing. Neglecting to clean a wound can lead to complications and prolong the healing process. Educationally, it is crucial to teach proper wound care techniques to promote optimal healing outcomes. Emphasizing the use of gentle, isotonic solutions like saline can help students understand the importance of maintaining a clean wound environment while minimizing tissue damage. Encouraging evidence-based practices in wound care will equip students with valuable skills to provide effective care in various healthcare settings.

Correct Answer: C

Rationale: The correct answer is C) the threat to his self-image. Psoriasis is a chronic skin condition that can have a significant impact on a person's physical appearance, leading to feelings of embarrassment, self-consciousness, and low self-esteem. The emotional impact of psoriasis often stems from the visible nature of the condition, which can result in social stigma and negative perceptions from others. This can lead to psychological distress and a diminished quality of life for individuals living with psoriasis. Option A) its effect on the central nervous system is incorrect because while psoriasis is an immune-mediated condition, its emotional impact is more closely tied to the psychological and social aspects rather than direct effects on the central nervous system. Option B) the effects of the drugs used to treat the psoriasis is incorrect because while some medications used to treat psoriasis may have side effects, the emotional impact primarily arises from the visibility of the skin condition itself rather than the treatment modalities. Option D) the fear of dying is incorrect as psoriasis is not a life-threatening condition, and the emotional impact typically revolves around the challenges of managing a chronic skin condition rather than fear of mortality. In an educational context, understanding the emotional impact of psoriasis is crucial for healthcare professionals working with patients with this condition. By recognizing the psychosocial challenges faced by individuals with psoriasis, healthcare providers can offer holistic care that addresses not only the physical symptoms but also the emotional well-being of the patient. This knowledge can help improve patient outcomes and overall quality of life for individuals living with psoriasis.

Correct Answer: A

Rationale: In the resuscitative phase of care for a patient like Mr. Aspen, monitoring urine output is crucial as it provides essential information about kidney function and fluid balance. This is important for assessing the effectiveness of resuscitation efforts and ensuring adequate organ perfusion. Option A is correct because in critically ill patients, maintaining adequate urine output is indicative of sufficient cardiac output and renal perfusion, which are essential for overall patient stability and recovery. Option B, pain level, while important, is not the most critical variable to monitor during the resuscitative phase. Pain management is crucial for patient comfort, but it does not directly impact physiological stability in the same way urine output does. Option C, central venous pressure, may provide information about fluid status, but it is not as reliable or immediate as monitoring urine output in assessing kidney function and fluid balance during resuscitation. Option D, progression of wound healing, is not a priority during the resuscitative phase when the focus is on stabilizing vital functions and ensuring organ perfusion. Educationally, this question highlights the importance of prioritizing key physiological parameters in the management of critically ill patients and underscores the significance of monitoring urine output as a vital sign in assessing fluid status and renal function.

Correct Answer: A

Rationale: The correct answer is A) partial-thickness. In this scenario, the burn described with intact large blisters, a broken blister, redness, and moisture indicates a partial-thickness burn. This type of burn affects the epidermis and part of the dermis layer of the skin, leading to blister formation and skin redness. Option B) first-degree burn only affects the epidermis and presents with redness and pain but no blister formation, which does not align with the described scenario. Option C) full-thickness burn would involve damage to the entire epidermis and dermis, leading to a dry, leathery appearance and less moisture compared to the description provided. Option D) third-degree burns extend through all skin layers and often appear charred or white, which is not consistent with the moist, blistering wound described. For educational context, understanding the depth of a burn is crucial in determining the appropriate first aid care and subsequent medical treatment. Recognizing the characteristics of different burn depths can help individuals provide timely and effective care to minimize complications and promote healing.