Nursing diagnosis commonly used when working with Sandro is

Correct Answer: C

Rationale: When working with Sandro, who is taking an MAOI and needs to be educated on avoiding foods with tyramine, the nursing diagnosis commonly used would be "impaired social interaction." This nursing diagnosis focuses on the client's difficulty in establishing or maintaining meaningful relationships with others. In this case, Sandro's dietary restrictions due to his medication may cause challenges in social situations, leading to potential feelings of isolation or inability to engage in social activities involving food. By identifying impaired social interaction as a nursing diagnosis, the nurse can address these issues and support Sandro in maintaining social connections while adhering to his dietary requirements.

Correct Answer: A

Rationale: Aplastic anemia is a condition characterized by a reduction in the number of all three blood cell types: red blood cells, white blood cells, and platelets. The patient's presentation of bone pain, fatigue, frequent infections, pancytopenia (decreased counts of all blood cell types), hypocellular bone marrow (reduced cellularity in the bone marrow), and absence of reticulocytes is indicative of aplastic anemia.

Correct Answer: C

Rationale: If Jose is complaining of dyspnea despite continuous oxygen therapy, the nurse's initial intervention should be to assess the patency of the tubing delivering the oxygen. A blockage in the tubing could restrict the flow of oxygen to the patient, leading to inadequate oxygen delivery and worsening dyspnea. By ensuring the tubing is clear and functioning properly, the nurse can address a potential issue with oxygen delivery before considering other interventions like giving PRN medication or involving the physician. Re-assessing the patient would also be important after ensuring the tubing's patency to evaluate the effectiveness of the intervention.

Correct Answer: D

Rationale: The appropriate nursing diagnosis for this situation is "Ineffective coping" because the patients with hypertension who stop taking their medications despite feeling good may be using this behavior as a maladaptive coping mechanism. It suggests that they might not fully understand the importance of medication adherence or are struggling to accept their diagnosis. By not adhering to their prescribed treatment, they are putting themselves at risk for complications associated with uncontrolled hypertension. Therefore, the nursing diagnosis of "Ineffective coping" addresses the patients' inability to deal with their condition in a healthy manner, leading to noncompliance with their treatment regimen.

Correct Answer: B

Rationale: An abdominal ultrasound is the imaging test that uses a transducer and is most commonly ordered by physicians to detect gallstones. This non-invasive procedure allows the physician to visualize the gallbladder and detect any presence of gallstones. The transducer emits sound waves that bounce off the gallstones, creating images that can be seen on a screen. This imaging test is safe, reliable, and effective in diagnosing gallstones without the use of radiation or contrast dye.

Correct Answer: B

Rationale: In assessing the health condition of school children, anemia and other blood disorders are more commonly observed in this age group compared to cancer, lice, parasites, fractures, and injuries. Anemia is a common health issue among children due to various factors such as poor nutrition, iron deficiency, and infections. Regular screening for anemia is important in school-age children to prevent long-term complications and to promote their overall health and well-being. While cancer, lice, parasites, fractures, and injuries can also occur in school children, anemia and blood disorders are more prevalent in this age group.

Correct Answer: A

Rationale: Acute splenic sequestration crisis is a complication seen in patients with sickle cell disease characterized by the sudden pooling of sickled red blood cells in the spleen, leading to splenic enlargement, severe anemia, and hypovolemic shock. This pooling results in a rapid drop in hemoglobin levels, causing anemia. The spleen's sequestration of large numbers of red blood cells can cause a sudden rise in the number of immature red blood cells (reticulocytes) in the blood (reticulocytosis). The destruction of these trapped red blood cells in the spleen leads to hemolysis, evidenced by elevated indirect bilirubin levels and the presence of Howell-Jolly bodies (nuclear remnants of erythrocytes) on peripheral blood smear. Patients may present with severe abdominal pain, fever, jaundice, and signs of hemodynamic instability, which

Correct Answer: C

Rationale: Anticonvulsant medications, such as phenytoin and phenobarbital, can interfere with pregnancy tests by affecting the levels of human chorionic gonadotropin (hCG) in the body. HCG is the hormone detected in pregnancy tests. These medications may potentially lead to a false-negative result on a pregnancy test for women who are actually pregnant. Therefore, in the case of Almira, who is 6 months pregnant and taking anticonvulsant medication due to the risk of producing a false-negative pregnancy test result, healthcare providers should consider other clinical indicators, such as abdominal cramps and vaginal spotting, to assess her pregnancy status.

Correct Answer: B

Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.