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?

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Question 1 of 5

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.

Question 2 of 5

A patient has sought care, stating that she developed hives overnight. The nurses inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?

Correct Answer: A

Rationale: The correct answer is A: Type I hypersensitivity reaction. This type of reaction involves the release of histamine from mast cells and basophils, leading to symptoms like hives. It is characterized by the involvement of IgE antibodies. In this case, the patient developed hives quickly after exposure to the allergen, indicating an immediate hypersensitivity reaction typical of Type I. Choices B, C, and D are incorrect because they are associated with different mechanisms and timeframes of hypersensitivity reactions. Type II involves antibody-mediated cell destruction, Type III involves immune complex deposition, and Type IV is a delayed-type hypersensitivity reaction mediated by T cells, none of which are consistent with the rapid onset of hives seen in this patient.

Question 3 of 5

A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurses priority for care?

Correct Answer: B

Rationale: The correct answer is B: Protect the patient's airway. In anaphylaxis, airway compromise can lead to respiratory distress and even respiratory arrest. The priority is to ensure the patient has a patent airway to maintain oxygenation. This can be achieved through interventions such as positioning, oxygen therapy, and potentially intubation if needed. Monitoring the patient's level of consciousness (A) is important but secondary to ensuring airway patency. Providing psychosocial support (C) is not the immediate priority in anaphylaxis. Administering medications (D) is also important but only after ensuring the airway is protected.

Question 4 of 5

The nurse is providing preoperative education for a patient diagnosed with endometriosis. A hysterectomy has been scheduled. What education topic should the nurse be sure to include for this patient?

Correct Answer: D

Rationale: The correct answer is D because it addresses a crucial aspect of preoperative care for a patient undergoing a hysterectomy due to endometriosis. Emptying the bladder before surgery helps prevent urinary retention postoperatively. Placing a catheter during surgery ensures proper drainage and prevents bladder distention. This education topic is essential for the patient's comfort and well-being during and after the procedure. Choices A, B, and C are incorrect: A: Menstrual periods will not continue after a hysterectomy as the uterus is removed. B: Normal activity is usually restricted after a hysterectomy to promote healing. C: Hormone levels are affected after a hysterectomy, especially if the ovaries are also removed.

Question 5 of 5

A patient with ovarian cancer is admitted to the hospital for surgery and the nurse is completing the patients health history. What clinical manifestation would the nurse expect to assess?

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.

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