In the nursing diagnosis 'Disturbed Self-Esteem related to presence of large scar over left side of face,' what part of the nursing diagnosis is 'presence of large scar over left side of face'?

Correct Answer: A

Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors of the identified problem. In this case, the large scar over the left side of the face is the reason for the disturbed self-esteem. It is the underlying factor that is leading to the self-esteem issue. The problem itself is the disturbed self-esteem, the defining characteristics are the signs and symptoms that support the diagnosis, and client need is the desired outcome or goal for the client. In summary, the presence of the large scar is the cause or etiology of the disturbed self-esteem, making it the correct choice.

Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation. Incorrect Choices: A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns. C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication. D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.

Correct Answer: B

Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because: A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression. C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding. D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.

Correct Answer: A

Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors of the identified problem. In this case, the large scar over the left side of the face is the reason for the disturbed self-esteem. It is the underlying factor that is leading to the self-esteem issue. The problem itself is the disturbed self-esteem, the defining characteristics are the signs and symptoms that support the diagnosis, and client need is the desired outcome or goal for the client. In summary, the presence of the large scar is the cause or etiology of the disturbed self-esteem, making it the correct choice.

Correct Answer: A

Rationale: The correct answer is A: It is associated with stages 1 and 2 hypertension. Smoking is a major risk factor for developing hypertension, especially stages 1 and 2. Nicotine in cigarettes can lead to vasoconstriction, increased heart rate, and overall elevated blood pressure. This information is crucial for patients to understand the direct impact of smoking on their blood pressure levels. Choice B is incorrect because smoking does indeed affect BP regulation by causing vasoconstriction and elevated heart rate. Choice C is incorrect as smoking actually causes vasoconstriction rather than vasodilation. Choice D is incorrect because smoking does lead to sustained elevation of blood pressure, especially in the long term.

Correct Answer: C

Rationale: The correct answer is C: Health promotion. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition. Incorrect choices: A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it. B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed. D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.

Correct Answer: A

Rationale: The correct answer is A: The client’s airway should be assessed first. This is because airway management is the top priority in any emergency situation to ensure the patient can breathe. Without a patent airway, the patient's oxygenation and ventilation will be compromised, leading to serious complications or death. Choices B, C, and D are incorrect because assessing the airway takes precedence over determining the reason for admission, reviewing medications, or assessing past medical history in an unconscious patient. These other assessments are important but not as critical as securing the airway to maintain the patient's breathing and oxygenation.

Correct Answer: D

Rationale: Step 1: Levothyroxine (Synthroid) is the synthetic form of the thyroid hormone T4, the main hormone produced by the thyroid gland. Step 2: Levothyroxine is the preferred agent for thyroid hormone replacement therapy in hypothyroidism due to its stable and consistent potency. Step 3: Levothyroxine is well-absorbed by the body and has a long half-life, allowing for once-daily dosing. Step 4: Other choices are incorrect because Methimazole is used to treat hyperthyroidism, Livothyronine is a form of T3 hormone not commonly used for replacement therapy, and Thyroid USP dessicated is derived from animal thyroid glands and has inconsistent hormone content. Summary: Levothyroxine (Synthroid) is the preferred choice for thyroid hormone replacement therapy due to its synthetic nature, stable potency, good absorption, and long half-life. Other options are not

Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.