The nursing diagnosis for a patient with a myocardial infarction is activity intolerance. The plan of care includes the patient outcome criterion of

Correct Answer: B

Rationale: In the context of a patient with a myocardial infarction diagnosed with activity intolerance, the correct outcome criterion is option B) ambulating 50 feet without experiencing dyspnea. This option is the most appropriate because it directly addresses the nursing diagnosis of activity intolerance by setting a measurable goal related to the patient's ability to engage in physical activity without experiencing shortness of breath. Option A) agreeing to discontinue smoking is important for overall cardiovascular health but does not directly address the patient's current activity intolerance. Option C) experiencing no dyspnea on exertion is a desirable outcome but may be too ambitious initially for a patient with activity intolerance. Option D) tolerating activity well is vague and not as specific or measurable as option B. In an educational context, understanding the rationale behind setting specific outcome criteria is crucial for effective nursing care planning. By setting measurable goals related to the patient's specific nursing diagnosis, nurses can track progress, evaluate effectiveness of interventions, and ensure patient-centered care. It is important for nurses to be able to critically think through different options to select the most appropriate and effective outcome criteria for each patient's unique situation.

Correct Answer: B

Rationale: In the context of a client admitted with portal hypertension, the priority nursing diagnosis would be option B) Potential complication hemorrhage. Portal hypertension is a condition where there is increased pressure in the portal vein system, leading to potential complications such as variceal bleeding. Immediate assessment and intervention to prevent hemorrhage are crucial in this situation. Option A) Altered nutrition: less than body requirements may be a concern for these patients in the long term, but it is not the priority when the immediate risk is hemorrhage. Option C) Ineffective individual coping may be relevant but is not as urgent as preventing potential hemorrhage. Option D) Fluid volume excess is not typically associated with portal hypertension, making it less relevant in this scenario. Educationally, this question highlights the importance of prioritizing nursing diagnoses based on the client's immediate needs and potential complications. It underscores the critical thinking skills required in assessing and planning care for patients with complex medical conditions.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D: Determine the client's understanding of her colostomy. This is the most appropriate initial action by the nurse because it addresses the client's emotional distress and allows the nurse to assess the client's knowledge and perception of the colostomy. By understanding the client's understanding, the nurse can provide education, support, and address any misconceptions or fears that the client may have. Option A (Arrange a consultation with a sex therapist) is incorrect as it does not address the immediate emotional needs of the client or the underlying issue of body image concerns related to the colostomy. Option B (Suggest sexual positions that hide the colostomy) is inappropriate as it focuses on superficial solutions rather than addressing the client's emotional distress. Option C (Invite the partner to participate in colostomy care) may be beneficial in the long run but does not address the client's immediate emotional needs or concerns. Educationally, this scenario highlights the importance of holistic care in nursing. It emphasizes the need for nurses to address not only the physical aspects of care but also the emotional and psychological well-being of their patients. By prioritizing communication, empathy, and patient education, nurses can provide comprehensive care that promotes healing and overall well-being.

Correct Answer: D

Rationale: The correct answer is D) To reduce the tendency of the client to hide objects under his or her clothing. In a unit where clients may have eating disorders, there is a risk that they may try to conceal objects to manipulate their weight during weigh-ins. This practice helps ensure accurate weight measurements and prevents any potential harm to the client's health. Option A is incorrect because weighing in a hospital gown does not primarily serve to reduce the risk of the client feeling cold. Option B is incorrect as covering bony prominences and areas with skin breakdown would be more related to pressure ulcer prevention than weighing accuracy. Option C is also incorrect as the client's choice of clothing is not the focus when it comes to weighing for clinical purposes. In an educational context, it is crucial for healthcare professionals working in units that treat eating disorders to understand the rationale behind specific protocols to provide safe and effective care for their clients. By ensuring accurate weight recordings, healthcare providers can better monitor a client's progress and tailor treatment plans accordingly.

Correct Answer: B

Rationale: In caring for a newborn infected with HIV in utero, the nurse must consider that option B) "The infant is very susceptible to infections" is correct. HIV compromises the immune system, making the infant highly vulnerable to infections. This susceptibility puts the infant at risk for severe complications and necessitates meticulous infection control measures and prompt treatment of any infections that may arise. Option A is incorrect because HIV does not necessarily have a longer incubation period or slower progression in infants. Option C is incorrect as HIV can impact growth and development due to its effects on the immune system. Option D is incorrect as renal monitoring is not the primary concern when caring for an HIV-infected newborn; infection prevention and immune support are the primary focuses. This educational context highlights the critical importance of understanding the unique needs of infants born with HIV and emphasizes the significance of providing appropriate care to ensure their well-being and quality of life.