Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, 'I'd rather stay in my room and listen to music. It's easier than thinking about what is happening in my family.' Which nursing diagnosis is most applicable?

Correct Answer: C

Rationale: The correct answer is C: Defensive coping related to adjustment to changes in family relationships. The adolescent's behavior of truancy and assault is a coping mechanism to avoid dealing with the stress and turmoil caused by the parents' divorce. This choice addresses the underlying issue of struggling to adjust to the changes in family dynamics and using defensive coping mechanisms to deal with the emotional distress. A: Chronic low self-esteem is not the most appropriate diagnosis in this case as the behavior exhibited is more related to coping with family changes rather than self-esteem issues. B: Decisional conflict related to school compliance is not the best choice as the behavior is not primarily driven by conflicts related to school requirements. D: Disturbed personal identity related to changing family dynamics is not the most suitable diagnosis as the primary issue lies in the coping mechanism and adjustment to family changes rather than personal identity disturbances.

Correct Answer: A

Rationale: The correct answer is A because the assessment findings of being negative, hostile, and spiteful toward parents, and blaming others for misbehavior align with Oppositional Defiant Disorder (ODD) criteria. This behavior pattern is a key characteristic of ODD, where individuals often display defiance and hostility towards authority figures. Choice B describes symptoms of Tourette syndrome, not ODD. Choice C describes conduct disorder behaviors, not specific to ODD. Choice D is unrelated to ODD symptoms.

Correct Answer: C

Rationale: The correct answer is C because it specifically asks about the patient's difficulty in walking a quarter of a mile, which assesses their capacity for functional activities. This question focuses on a specific distance and activity, providing a clear indication of the patient's ability to participate in a common daily task. Choice A is too general and does not specify a distance or activity, making it less effective in assessing functional capacity. Choice B focuses on the effect of an assistive device rather than the patient's actual ability to perform the activity. Choice D asks about going up and down stairs, which is not as indicative of overall functional capacity compared to walking a quarter of a mile.

Correct Answer: A

Rationale: The correct answer is A. Sitting with the arm in a horizontal, supported position at heart level is recommended for consistent blood pressure measurements because it helps reduce errors due to gravitational effects. Placing the arm at heart level minimizes the hydrostatic pressure changes, ensuring accurate readings. This position also allows for proper cuff placement and comfortable arm support, leading to more reliable results. Summary: Choice B (Supine position with arm resting comfortably on the chest) may lead to inaccurate readings due to the arm position not being at heart level. Choice C (Sitting on the couch with arm resting comfortably by the side) lacks the necessary arm support and heart level positioning, leading to potential errors. Choice D (Standing with arm by side and cuff positioned at heart level) may result in fluctuating readings due to the effect of gravity on blood pressure when standing.

Correct Answer: C

Rationale: The correct answer is C: Popliteal aneurysm. Popliteal aneurysm is a potentially serious condition that can lead to compression of surrounding structures, including the popliteal artery. In this case, the easily palpable popliteal pulse and the lower blood pressure in the affected lower limb suggest a potential obstruction or dilation of the popliteal artery, which could be indicative of a popliteal aneurysm. This condition needs to be ruled out urgently due to the risk of complications such as thrombosis or rupture. Choice A: Deep venous thrombosis is unlikely in this case as there are no signs or symptoms suggestive of venous thrombosis, and the presence of a palpable pulse indicates arterial involvement. Choice B: Restless leg syndrome is a neurological disorder characterized by an uncontrollable urge to move the legs, and it does not present with the physical findings described in the scenario. Choice D: Femoral artery occlusion is