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: B

Rationale: The correct answer is B because the patient's inability to count fingers indicates severe visual impairment. Testing hand motion perception is a more appropriate initial assessment for patients with such significant visual losses. This method can differentiate between light perception and no light perception, providing valuable information about the patient's visual acuity. The other choices are incorrect because assessing vision using a Snellen chart (A) requires more visual acuity than just being able to see hand motion. Performing a detailed examination of external eye structures (C) and palpating periocular regions (D) are not relevant for assessing visual acuity and do not provide information on the patient's ability to perceive hand motion.

Correct Answer: C

Rationale: The correct answer is C: Clinical decision support system. A clinical decision support system is a type of system or design that helps healthcare professionals, including nurses, in making clinical decisions by providing them with relevant information and knowledge. This system assists in analyzing data to generate patient-specific recommendations or alerts to improve patient care. In the given scenario, the nurse's need to find, evaluate, and use information effectively aligns with the purpose of a clinical decision support system. This system enables the nurse to access evidence-based information, guidelines, and recommendations to enhance their decision-making process and improve patient outcomes. Summary of why other choices are incorrect: A: Computer competency does not equate to informatics competency. While computer skills are important, informatics involves a deeper understanding of using information effectively in practice. B: This choice provides a detailed explanation of informatics but does not directly address the type of system or design the nurse would be using to find, evaluate, and use information effectively. D: Nursing process

Correct Answer: A

Rationale: The correct answer is A: Anaphylactic reaction after a bee sting. Type I hypersensitivity reactions involve an immediate response triggered by exposure to an allergen, leading to the release of histamine and other inflammatory mediators. In this case, a bee sting would introduce an allergen, causing a rapid and severe systemic reaction, known as anaphylaxis. B: Skin reaction resulting from adhesive tape is an example of a Type IV hypersensitivity reaction, mediated by T cells, not IgE antibodies as in Type I reactions. C: Myasthenia gravis is an autoimmune disorder involving antibodies attacking acetylcholine receptors, not a Type I hypersensitivity reaction. D: Rheumatoid arthritis is an autoimmune disorder involving immune complexes and inflammatory responses, not a Type I hypersensitivity reaction.

Correct Answer: B

Rationale: The correct answer is B: Jejunostomy tube. This tube is chosen because the patient has a history of aspiration pneumonia, which puts them at risk for aspiration if feeds are administered into the stomach. By administering feeds through a jejunostomy tube, the risk of aspiration pneumonia is minimized as the feed bypasses the stomach. Nasogastric tube (A) and Nasointestinal tube (C) would still deliver feeds to the stomach, increasing the risk of aspiration. PEG tube (D) is also not ideal as it delivers feeds directly to the stomach, which is not recommended for patients at risk for aspiration.

Correct Answer: C

Rationale: The correct answer is C because providing individualized care is a fundamental aspect of cultural competence. This means tailoring care to meet the unique cultural, social, and personal needs of each patient. It involves understanding and respecting a patient's beliefs, values, and practices. Explanation: A. Providing care to transgender patients is important, but it is not the primary goal of cultural competence. B. Restoring relationships is beneficial but may not directly address cultural competence. D. Providing care to surgical patients is a common nursing duty but does not specifically relate to cultural competence.

Correct Answer: A

Rationale: The correct answer is A: When the patient is resting. This is because the tremor associated with Parkinson's disease is most noticeable when the patient is at rest due to the characteristic "resting tremor" seen in this condition. The tremor tends to lessen or disappear with purposeful movements or activities, making it more difficult to assess during ambulation, meal preparation, or occupational therapy. By observing the patient at rest, the nurse can accurately assess the presence and severity of the tremor, which is a key diagnostic feature of Parkinson's disease. Other answer choices are incorrect because they do not provide the optimal condition for assessing the tremor associated with Parkinson's disease.

Correct Answer: B

Rationale: The correct answer is B: Cholesteatoma. A red blemish behind the tympanic membrane is indicative of a cholesteatoma, which is a noncancerous cyst in the middle ear. This occurs due to the accumulation of skin cells and debris in the middle ear space. Other choices (A, C, D) are not associated with a red blemish on otoscopy. An acoustic tumor (A) typically presents as a slow-growing mass on the vestibulocochlear nerve. Facial nerve neuroma (C) involves the facial nerve and does not typically cause a red blemish. Glomus tympanicum (D) is a vascular tumor arising from the middle ear but does not usually present as a red blemish.

Correct Answer: B

Rationale: The correct answer is B: Increased abdominal girth. In ovarian cancer, a common clinical manifestation is the accumulation of fluid in the abdomen, leading to increased abdominal girth. This is known as ascites. The presence of ascites can be observed through physical examination and abdominal imaging. A: Fish-like vaginal odor is not typically associated with ovarian cancer. It may be a symptom of other gynecological conditions. C: Fever and chills are not specific to ovarian cancer and can be seen in various infectious or inflammatory conditions. D: Lower abdominal pelvic pain is a common symptom in many gynecological conditions but is not a specific manifestation of ovarian cancer.