A woman wears a size 7 shoe. She says, My feet are huge. I've asked three orthopedists to surgically reduce my feet. The patient tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?

Correct Answer: C

Rationale: The correct answer is C: Body dysmorphic disorder. This disorder involves a preoccupation with perceived flaws in physical appearance that are not observable to others. In this case, the woman's belief that her feet are huge despite wearing a size 7 shoe indicates a distorted body image. She seeks surgical interventions and hides her feet, which are characteristic behaviors of individuals with body dysmorphic disorder. A: Dissociative amnesia with fugue involves memory loss and wandering behavior, which are not exhibited in this scenario. B: Illness anxiety disorder involves excessive worry about having a serious illness, which is not the focus of the woman's concern. D: Dissociative identity disorder involves the presence of two or more distinct identities or personality states, which is not evident in this case.

Correct Answer: A

Rationale: The correct answer is option A) Acute Pain related to biologic and chemical factors. The priority nursing diagnosis for a patient experiencing a migraine headache is acute pain because it addresses the immediate and most distressing issue the patient is facing. Migraine headaches are characterized by severe and debilitating pain, making pain management a crucial aspect of care. Option B) Anxiety related to change in or threat to health status may be a secondary nursing diagnosis for a patient with a migraine, but it is not the priority over addressing the acute pain. Option C) Hopelessness related to deteriorating physiological condition is not the priority in this case as migraines, though severe, are typically episodic and not indicative of a deteriorating physiological condition. Option D) Risk for Side Effects related to medical therapy is not the priority nursing diagnosis when the patient is currently experiencing a migraine headache. Managing the acute pain takes precedence over potential side effects of treatment. In an educational context, understanding the priority nursing diagnosis helps students and healthcare professionals prioritize patient care and address the most urgent needs first. By focusing on acute pain management in this case, the nurse can provide timely and effective relief to improve the patient's comfort and overall well-being.

Correct Answer: A

Rationale: The correct answer is A) A 34-year-old patient newly diagnosed with multiple sclerosis (MS). This patient is the most suitable for assignment to the traveling nurse new to neurologic nursing care due to several reasons. Firstly, a newly diagnosed MS patient would likely not have complex care needs compared to patients with chronic conditions like ALS or GBS in respiratory distress. This would provide a good learning opportunity for the new nurse to gain confidence and skills in managing neurologic conditions. Additionally, as a newly diagnosed patient, there may be a focus on education, symptom management, and emotional support, which aligns well with the new nurse's learning objectives. Option B) The 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS) may have complex care needs and require specialized care due to the progressive nature of the disease. The new nurse may not have the experience or skills yet to effectively manage the care needs of a patient with ALS. Option C) The 56-year-old patient with Guillain-Barré syndrome (GBS) in respiratory distress requires urgent and specialized care, including respiratory support. This patient's condition is critical and may be overwhelming for a nurse who is new to neurologic nursing care. Option D) The 25-year-old patient admitted with C4 level spinal cord injury (SCI) may also have complex care needs, including potential respiratory issues and neurologic deficits. This patient would require a nurse with more experience in neurologic nursing care to provide comprehensive and safe management. Assigning the newly diagnosed MS patient to the traveling nurse would offer a suitable learning experience while ensuring safe and appropriate care for the patient. This scenario provides a balance between the patient's needs and the nurse's learning requirements, fostering professional growth and quality patient care.

Correct Answer: D

Rationale: In this scenario, the correct observation that the LPN/LVN should report immediately is option D) Shallow respirations and decreased breath sounds. This is crucial because Guillain-Barre Syndrome (GBS) can lead to respiratory muscle weakness, which can progress to respiratory failure and is a life-threatening complication. Option A) Complaints of numbness and tingling are common symptoms of GBS but do not indicate an immediate life-threatening situation. Option B) Facial weakness and difficulty speaking are also signs of GBS but are not as critical as compromised respiratory function. Option C) Rapid heart rate of 102 beats per minute is not uncommon in patients with GBS due to autonomic dysfunction, but it is not as urgent as respiratory distress. Educationally, understanding the priority of assessments in neurological conditions like GBS is crucial for patient safety. Teaching healthcare providers to recognize and respond promptly to respiratory changes can prevent serious complications and improve patient outcomes in neurological emergencies.

Correct Answer: B

Rationale: The most appropriate nursing diagnosis for this patient is B) Caregiver Role Strain related to continuous need for providing care. This diagnosis is correct because the husband's statement indicates that he is experiencing strain and stress due to the constant need to monitor and care for his wife, who has Alzheimer's disease and is at risk of wandering during the night. This situation places a significant burden on the caregiver and can lead to physical, emotional, and mental exhaustion. Option A) Decreased Cardiac Output related to poor myocardial contractility is incorrect because there is no direct evidence in the scenario to support this nursing diagnosis. The patient's angina and Alzheimer's disease are not linked to poor myocardial contractility. Option C) Risk for Falls related to patient wandering behavior during the night is incorrect because while the patient's wandering behavior does pose a risk for falls, the focus of the question is on the caregiver's well-being, not solely on the patient's safety. Option D) Ineffective Therapeutic Regimen Management related to poor patient memory is incorrect because the husband's actions do not suggest an issue with the patient's memory affecting her ability to manage her therapeutic regimen. Instead, the scenario highlights the caregiver's struggle in managing the care of a patient with Alzheimer's disease. In an educational context, understanding and identifying caregiver role strain is crucial in providing holistic care to patients with chronic conditions like Alzheimer's disease. Nurses need to assess not only the patient's well-being but also the caregiver's ability to cope with the demands of caregiving. By recognizing and addressing caregiver role strain, healthcare professionals can support both the patient and the caregiver in maintaining their health and well-being.