or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?

Correct Answer: C

Rationale: The most appropriate expected outcome for a client experiencing anxiety related to a cancer diagnosis would be "Client uses any effective method to reduce tension." This outcome focuses on the client actively managing their anxiety by utilizing various strategies to decrease tension and promote feelings of calmness. It empowers the client to take control of their anxiety and seeks to foster a sense of well-being during a difficult time. The other options do not directly address the active management of anxiety as effectively as option C.

Correct Answer: A

Rationale: Clubbing of fingers is a common physiologic adaptation seen in children with tetralogy of Fallot. Clubbing is the result of chronic hypoxia and decreased oxygen levels in the blood. In children with tetralogy of Fallot, there is a structural defect in the heart that leads to mixing of oxygenated and deoxygenated blood in the heart and decreased oxygenation of the blood circulating to the body. This chronic hypoxia can cause clubbing of the fingers, where the tips of the fingers appear enlarged and the nails are rounded. Therefore, clubbing of fingers is a key sign to monitor in children with tetralogy of Fallot.

Correct Answer: B

Rationale: Hypernatremia is a condition characterized by high levels of sodium in the blood. When hypernatremia is treated too rapidly or aggressively, a rapid decrease in serum sodium levels may occur. This rapid change in serum sodium concentration can cause water to move into brain cells, leading to cerebral edema. Cerebral edema is a dangerous complication associated with the potential to cause increased intracranial pressure, neurological deficits, and even death. It is crucial to correct hypernatremia slowly and carefully to prevent such complications.

Correct Answer: B

Rationale: Recent research suggests that the majority of peptic ulcers are caused by an infection with Helicobacter pylori bacteria. This bacterium weakens the protective mucous coating of the stomach and duodenum, leading to damage from stomach acid. Genetic defects in the gastric mucosa, high fat diet, and work-related stress may exacerbate the condition but are not the primary cause of peptic ulcers. Therefore, the most likely cause based on current understanding is H. pylori infection.

Correct Answer: D

Rationale: Parents should be encouraged to name their newborn if they have not done so already because giving the baby a name can help the parents acknowledge their baby as a unique individual. It can also provide a sense of connection and identity, which can be important for the grieving process and coping with the loss. Naming the baby allows the parents to honor their child's existence and memory, and it can be a meaningful part of their healing journey.

Correct Answer: A

Rationale: The anterior fontanel, also known as the bregma, is the larger of the two fontanels located on the baby's skull. It is diamond-shaped, with the sutures meeting in the center to create a space that is soft and slightly depressed. While it is diamond-shaped when looking at the intersection of the sutures, when palpated or touched by a nurse, it often feels more circular due to the softness of the fontanel. It is important for nurses to monitor the fontanels for normal closure and development in newborns.

Correct Answer: B

Rationale: A client with a cerebellar brain tumor is likely to experience impaired balance due to the location of the tumor affecting the cerebellum, which is responsible for coordinating movement and balance. Impaired balance increases the risk for falls and other injuries, making it a priority concern for the client. Therefore, adding "Related to impaired balance" to the nursing diagnosis statement would be the most appropriate choice to address the client's risk for injury in this situation.

Correct Answer: C

Rationale: Breastfeeding can continue even with a hip spica cast, but proper positioning is essential to ensure comfort for both the infant and the mother.

Correct Answer: B

Rationale: Hyperdiploidy is associated with a better prognosis in neuroblastoma.