The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patients care plan?

Correct Answer: D

Rationale: The correct answer is D: Risk for Self-Care Deficit Related to Skin Lesions. Patients with atopic dermatitis may experience difficulty performing self-care tasks due to pain, itching, and limitations in hand mobility caused by skin lesions. This diagnosis addresses the potential challenges the patient may face in maintaining personal hygiene and managing their skin condition. Explanation for why other choices are incorrect: A: Risk for Disturbed Body Image Related to Skin Lesions - While atopic dermatitis may impact body image, the priority in this case is the patient's ability to perform self-care. B: Risk for Disuse Syndrome Related to Dermatitis - Disuse syndrome is not typically associated with atopic dermatitis. C: Risk for Ineffective Role Performance Related to Dermatitis - This diagnosis focuses on the patient's ability to fulfill their roles, which may not be directly impacted by atopic dermatitis.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): 1. The newer antihistamines, such as second-generation antihistamines like loratadine or cetirizine, are designed to cause less sedation compared to older antihistamines like diphenhydramine. 2. These newer antihistamines have a lower affinity for crossing the blood-brain barrier, reducing the sedative effects. 3. Therefore, suggesting that the newer antihistamines are different and cause less sedation is the best response to address the patient's concerns. Summary of Incorrect Choices: A. While some newer antihistamines may be combined with decongestants to offset drowsiness, this is not a consistent feature of all newer antihistamines. B. Developing tolerance to sedation after a few months is not a common or reliable response to antihistamines. D. Taking antihistamines at bedtime may help with sedation, but it does not address

Correct Answer: D

Rationale: The correct answer is D because setting the scanner to female is incorrect for a patient who has had a hysterectomy as they do not have a uterus. This could lead to inaccurate results. Palpating the symphysis pubis (A) ensures proper positioning, wiping the scanner head with alcohol (B) maintains infection control, and applying gel (C) facilitates sound wave transmission.

Correct Answer: A

Rationale: The correct answer is A: Ask if he would like you to sit with him while he collects his thoughts. Rationale: 1. Active listening: By offering to sit with him, you show empathy and support his emotional expression. 2. Respect his autonomy: Asking if he would like you to sit allows him to make a choice about what support he needs. 3. Nonjudgmental approach: Sitting with him creates a safe space for him to share his feelings without feeling rushed or judged. Summary: B: Leaving abruptly may make him feel abandoned in a vulnerable moment. C: While spiritual support can be beneficial, it may not address his immediate emotional needs. D: Reassurance is important but may not be as effective as actively listening and offering support in this context.

Correct Answer: C

Rationale: The correct answer is C: Western blot test. The Western blot test is considered the gold standard for confirming HIV diagnosis after a positive EIA result. It detects specific antibodies to HIV proteins, providing a more accurate confirmation. Other choices are incorrect because: A: Another EIA test would yield the same result as the initial EIA test. B: Viral load test measures the amount of virus in the blood and is not used to confirm HIV diagnosis. D: CD4/CD8 ratio is used to monitor immune status but not to confirm HIV diagnosis.

Correct Answer: D

Rationale: The correct answer is D because it provides an accurate and comprehensive response to the pregnant patient's question about the risk of her baby being born with HIV. Here's the step-by-step rationale: 1. Option D acknowledges the possibility of the baby contracting HIV at different stages: before, during, or after delivery. This covers all potential scenarios and educates the patient about the risks. 2. By mentioning the different possible transmission times, the nurse highlights the importance of proper prenatal care, delivery planning, and postnatal care to minimize the risk of HIV transmission to the baby. 3. This response empowers the patient with knowledge about the potential risks and emphasizes the importance of seeking appropriate medical interventions to prevent mother-to-child transmission of HIV. 4. In contrast, options A, B, and C provide less informative or inaccurate responses that do not address the patient's concerns adequately, making them incorrect choices. In summary, option D is the best response as it educates the patient about the risks of HIV transmission

Correct Answer: D

Rationale: The correct answer is D: Discuss a referral for hospice care. Hospice care provides specialized care for patients with terminal illnesses, focusing on comfort and quality of life. This option aligns with the patient's wish to die at home and ensures his care needs are met. Hospice care also provides emotional and spiritual support for both the patient and family. A: Discuss a referral for rehabilitation hospital - This option focuses on rehabilitation, which is not suitable for a patient with a terminal illness like extensive stage small-cell lung cancer. B: Panel the patient for a personal care home - Personal care homes may not provide the level of specialized care needed for a terminally ill patient. C: Discuss a referral for acute care - Acute care is more focused on treating acute illnesses and injuries, not providing end-of-life care for a patient with a terminal illness.

Correct Answer: C

Rationale: Correct Answer: C - Used crutches with no difficulties Rationale: 1. "Used crutches with no difficulties" reflects the patient's successful application of the taught skill. 2. This information indicates the patient's ability to independently perform the task. 3. It demonstrates the effectiveness of the teaching provided by the nurse. 4. "Used crutches with no difficulties" is a specific and objective observation of the patient's performance. Summary: A. "Patient went up and down stairs" is too general and does not indicate the patient's proficiency. B. "Demonstrated use of crutches" does not confirm the patient's actual performance. D. "Deficient knowledge related to never using crutches" is incorrect as it does not reflect the patient's successful use of crutches.

Correct Answer: B

Rationale: The correct answer is B: Report to the emergency department or employee health department. 1. Immediate action is crucial after exposure to HIV-positive blood. 2. Reporting to the emergency department or employee health department ensures prompt evaluation and appropriate management. 3. The supervisor should also be informed to initiate the necessary protocols. 4. The other choices are incorrect: - A: Chlorhexidine may not be sufficient for post-exposure prophylaxis. - C: Hydrocolloid dressing is not appropriate for managing needlestick injuries. - D: Following up with the primary care provider may cause delays in receiving timely post-exposure prophylaxis.