An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, 'I haven't had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I don't know if my heart is strong enough.' Which nursing diagnosis applies?

Correct Answer: A

Rationale: The correct answer is A: Deficient knowledge related to faulty perception of health status. The patient's statement indicates a lack of understanding about their health status and the impact of their myocardial infarction on their sexual activity. The patient is attributing their decreased interest in sex to a fear of straining their heart, indicating a faulty perception of their health status. This nursing diagnosis addresses the patient's need for education and clarification about their condition to alleviate their concerns and improve their confidence in engaging in sexual activity safely. Choices B, C, and D are incorrect because they do not directly address the patient's lack of knowledge and faulty perception about their health status. Disturbed self-concept (B) relates more to how the patient perceives themselves due to lifestyle changes, while disturbed body image (C) pertains to physical appearance changes. Sexual dysfunction (D) is related to difficulties in sexual function, which is not the primary issue in this scenario.

Correct Answer: C

Rationale: The correct answer is C because an advance directive is a legal document that specifies a person's wishes for healthcare decisions if they are unable to make decisions for themselves due to illness. This ensures their preferences are followed. Choices A and B are specific diagnoses and do not address decision-making capacity. Choice D focuses on the inability to speak, which is just one aspect of decision-making ability, but not comprehensive enough for an advance directive.

Correct Answer: A

Rationale: The correct answer is A: Gain 1 to 2 pounds. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). In anorexia nervosa, gaining weight is crucial for recovery. Weight gain indicates improved nutritional status and overall health. Option B is incorrect as excessive exercise can exacerbate the patient's condition. Option C is incorrect as laxative use is not a recommended treatment for anorexia nervosa. Option D is incorrect as self-weighing may lead to obsessive behavior in patients with eating disorders.

Correct Answer: B

Rationale: The correct answer is B because urine output less than 30 mL/hr indicates severe dehydration and compromised kidney function, which can lead to organ failure. Hospitalization is necessary for immediate fluid resuscitation and monitoring. Option A is indicative of malnutrition but does not directly signify acute medical complications. Option C suggests hypokalemia, which can be managed on an outpatient basis. Option D, a low pulse rate, may be a sign of bradycardia but typically does not require immediate hospitalization unless accompanied by other severe symptoms.

Correct Answer: D

Rationale: The correct answer is D, Fluphenazine (Prolixin), as it is a typical antipsychotic medication known to have strong anticholinergic effects. Anticholinergic side effects include dry mouth, constipation, blurred vision, and urinary retention. Fluphenazine blocks the action of acetylcholine in the brain, leading to these side effects. Choices A, B, and C are incorrect as they do not have significant anticholinergic effects compared to Fluphenazine. Lithium is a mood stabilizer, Buspirone is an anxiolytic, and Risperidone is an atypical antipsychotic, none of which are known for causing prominent anticholinergic side effects.