A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?

Correct Answer: C

Rationale: The correct answer is C: Disruption of tissue integrity. Acute pain is typically caused by tissue damage or injury, such as a cut or a burn. The nurse would use this assessment data as an etiology for acute pain because it directly relates to the source of the pain. Discomfort while changing position (A) is a symptom of pain but does not provide the underlying cause. Reports pain as a 7 on a 0 to 10 scale (B) is a pain intensity rating and does not explain the cause of the pain. Dull headache (D) is a specific type of pain but is not relevant to the given scenario of tissue disruption.

Correct Answer: B

Rationale: The correct answer is B: Hematuria. Bacillus Calmette-Guerin (BCG) is commonly used in the treatment of bladder cancer. It works by stimulating the immune system to attack and destroy cancer cells in the bladder. One of the common side effects of BCG instillations is hematuria, which is the presence of blood in the urine. This can occur due to irritation of the bladder lining by the BCG solution, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware of what to expect during treatment. A: Renal calculi - BCG therapy is not commonly associated with the formation of renal calculi. C: Delayed ejaculation - Delayed ejaculation is not a common side effect of BCG therapy. D: Impotence - Impotence is not a common side effect of BCG therapy.

Correct Answer: D

Rationale: The correct answer is D: Improve ability to hear. A hearing aid is designed to improve a person's ability to hear by amplifying sound. This helps individuals with hearing loss to better understand speech and sounds in their environment. A: Amplifying background noise is not the main purpose of a hearing aid. It may actually hinder the user's ability to focus on important sounds. B: Amplifying musical sounds is not the primary function of a hearing aid. The main focus is on improving speech understanding. C: Occluding the ear is not the purpose of a hearing aid. It is meant to enhance hearing, not block sound.

Correct Answer: C

Rationale: The correct answer is C, Disturbed body image related to the incision scar. This is the most appropriate nursing diagnosis as the client's concern about wearing a scarf around his neck post-surgery indicates a potential disturbance in body image. This diagnosis addresses the client's emotional response to physical changes, which is common in surgical patients. Choice A is incorrect because impaired physical mobility is not directly related to the client's worry about wearing a scarf. Choice B is incorrect as ineffective denial does not directly address the client's specific concern about body image. Choice D is also incorrect as the risk of injury is not the primary issue in this scenario; it is more about the client's perception of their appearance post-surgery. In summary, the client's worry about wearing a scarf post-surgery indicates a disturbance in body image, making choice C the most appropriate nursing diagnosis.

Correct Answer: B

Rationale: The correct answer is B. A semiprivate room with one or two consistent caregivers is the most therapeutic setting for an agitated head-injured patient. Here's the rationale: 1. Consistency: Having one or two consistent caregivers provides the patient with a stable and familiar environment, which can help reduce agitation. 2. Privacy: A semiprivate room offers more privacy compared to a day room or a ward, which can help minimize external stimuli and promote relaxation. 3. Individualized care: In a semiprivate room, caregivers can focus more on the specific needs of the patient, leading to better management of agitation. 4. Reduced distractions: Being in a semiprivate room minimizes distractions and noise, which can be overwhelming for an agitated head-injured patient. Summary: A, C, and D are incorrect because they do not offer the same level of consistency, privacy, individualized care, and reduced distractions as a semiprivate room with one

Correct Answer: C

Rationale: The correct answer is C. In hypothyroidism, the thyroid gland is underactive, leading to symptoms like puffiness of the face and hands due to fluid retention. This occurs as a result of decreased metabolism. Options A and B are symptoms of hyperthyroidism, where the thyroid gland is overactive. Option D is a symptom of goiter, which is thyroid gland swelling, not specific to hypothyroidism. Therefore, the correct answer is C based on the characteristic symptoms of hypothyroidism.

Correct Answer: A

Rationale: The correct answer is A: administer morphine sulfate as ordered. This is the appropriate nursing intervention because acute abdominal pain is a common symptom of acute pancreatitis, and morphine sulfate is a commonly used medication to relieve severe abdominal pain. Administering morphine sulfate will help alleviate Aling Loida's discomfort and improve her overall well-being. Choice B is incorrect because obtaining daily weights is not directly related to managing acute abdominal pain in this scenario. Choice C is incorrect as maintaining Aling Loida on a high calorie, high protein diet may exacerbate her symptoms due to the acute pancreatitis. Choice D is incorrect as placing her on a supine position may not address the underlying cause of the abdominal pain and could potentially worsen her condition.

Correct Answer: A

Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception. Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.

Correct Answer: C

Rationale: The correct answer is C: Weighing the client before and after the procedure. This is crucial as it helps monitor fluid removal during dialysis, ensuring the process is effective and safe. Weighing helps determine if the correct amount of fluid has been removed. A: Keeping dialysis supplies in a clean area is important for infection control but not a direct responsibility during the procedure. B: Inspecting the catheter insertion site for signs of infection is essential for monitoring the site's health but not a direct responsibility during dialysis. D: Washing hands before and after handling the catheter is a general infection control measure but not specific to the dialysis procedure itself.