What is the M0ST APPROPRIATE nursing diagnosis for this patient?

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.

Correct Answer: A

Rationale: The presentation of chest pain, dyspnea, hypotension, right ventricular dilation, and hypokinesis on echocardiogram is highly suggestive of a pulmonary embolism. In pulmonary embolism, a blood clot obstructs the pulmonary artery or one of its branches, leading to increased pressure in the right ventricle, which can cause right ventricular dilation and dysfunction. This results in the classic signs of right heart strain on echocardiogram. The patient may also present with symptoms of acute right heart failure, such as chest pain, dyspnea, and signs of hypotension. It is crucial to consider pulmonary embolism as a potential cause of these symptoms, given the high morbidity and mortality associated with this condition.

Correct Answer: C

Rationale: Bone pain in the back of the ribs is a classic manifestation of multiple myeloma. Multiple myeloma is a type of cancer that primarily affects plasma cells in the bone marrow, leading to weakened bones and bone pain. Patients with multiple myeloma often experience bone pain in areas such as the ribs, spine, and pelvis. The bone pain is typically persistent and worsens with movement or pressure. Additionally, other common symptoms of multiple myeloma include anemia, kidney damage, recurrent infections, and elevated calcium levels in the blood.

Correct Answer: B

Rationale: The epigastrium is the upper middle region of the abdomen, lying above the umbilical region and between the hypochondriac regions. It contains several organs including the duodenum, pancreas, portion of the liver, and the pyloric end of the stomach. The duodenum is the first part of the small intestine, the pancreas is a crucial organ for digestion and hormone regulation, the liver aids in digestion and detoxification, and the pyloric end of the stomach connects the stomach to the small intestine for further digestion and absorption of nutrients. These organs are typically assessed and examined when focusing on the epigastrium during a physical examination.

Correct Answer: B

Rationale: The nurse's priority action when noticing an abnormal heart rhythm on the patient's cardiac monitor during surgery is to assess the patient's vital signs and symptoms. This is important because the nurse needs to gather more information about the patient's condition to determine the significance of the abnormal rhythm and the potential impact on the patient's health. By assessing the vital signs and symptoms, the nurse can obtain a more complete picture of the situation and make informed decisions about the next steps in caring for the patient. Once the assessment is done, appropriate actions such as administering medication or notifying the anesthesiologist can be taken based on the findings.