What is the M0ST APPROPRIATE nursing diagnosis for this patient?

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Foundations and Adult Health Nursing Study Guide Answers Questions

Question 1 of 9

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.

Question 2 of 9

Friendly but professional overtures have finally made Marlene open up her circumstances to the nurse, including their financial difficulty. What has been established at this time?

Correct Answer: B

Rationale: Marlene opening up to the nurse about their financial difficulty indicates that she feels comfortable enough to share personal information with the nurse. This signals the establishment of a trusting relationship between Marlene and the nurse, as Marlene feels safe and supported enough to disclose sensitive information. Building trust is a crucial aspect of any professional relationship, especially in healthcare settings, as it fosters open communication, encourages honesty, and ultimately leads to better outcomes for the patient. It is an essential foundation for providing effective care and support to individuals in need.

Question 3 of 9

A patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with acute exacerbation and respiratory failure requiring mechanical ventilation. Which of the following ventilator settings is most appropriate for minimizing the risk of ventilator-induced lung injury (VILI) in this patient?

Correct Answer: A

Rationale: Patients with COPD are at increased risk for developing ventilator-induced lung injury (VILI) due to their underlying lung pathology. Using a low tidal volume strategy (6-8 ml/kg predicted body weight) has been shown to reduce the risk of VILI in these patients. Additionally, applying high positive end-expiratory pressure (PEEP) helps to recruit collapsed alveoli, improve oxygenation, and decrease the risk of barotrauma by keeping the alveoli open throughout the respiratory cycle. Therefore, the most appropriate ventilator settings to minimize the risk of VILI in a COPD patient with acute exacerbation and respiratory failure requiring mechanical ventilation would be low tidal volume and high PEEP.

Question 4 of 9

A patient presents with a palpable thyroid nodule and signs of hyperthyroidism. Fine-needle aspiration biopsy reveals follicular cells with nuclear features suggestive of malignancy. Which endocrine disorder is most likely responsible for these symptoms?

Correct Answer: D

Rationale: Follicular thyroid carcinoma is a type of thyroid cancer that arises from the follicular cells of the thyroid gland. Patients with follicular thyroid carcinoma may present with a palpable thyroid nodule, which in this case is causing signs of hyperthyroidism due to the overproduction of thyroid hormones by the malignant cells. Fine-needle aspiration biopsy revealing follicular cells with nuclear features suggestive of malignancy further supports the diagnosis of follicular thyroid carcinoma in this scenario.

Question 5 of 9

If Baby Sharon develops dehydration, what is the FIRST sign to look for by Nurse Juvy?

Correct Answer: B

Rationale: Sunken fontanels are one of the earliest signs of dehydration in infants. Fontanels are soft spots on an infant's head where the skull bones have not yet fused together. If a baby's fontanel appears sunken, it indicates that the baby is likely dehydrated. This occurs because when there is a lack of fluid in the body, the soft spots on the head will appear depressed or sunken. It is crucial for Nurse Juvy to closely monitor the fontanels of Baby Sharon, as identifying dehydration early is essential for prompt intervention and preventing complications.

Question 6 of 9

Nursing diagnosis commonly used when working with Sandro is

Correct Answer: C

Rationale: When working with Sandro, who is taking an MAOI and needs to be educated on avoiding foods with tyramine, the nursing diagnosis commonly used would be "impaired social interaction." This nursing diagnosis focuses on the client's difficulty in establishing or maintaining meaningful relationships with others. In this case, Sandro's dietary restrictions due to his medication may cause challenges in social situations, leading to potential feelings of isolation or inability to engage in social activities involving food. By identifying impaired social interaction as a nursing diagnosis, the nurse can address these issues and support Sandro in maintaining social connections while adhering to his dietary requirements.

Question 7 of 9

A patient expresses frustration with the long wait times in the healthcare facility. What is the nurse's best response?

Correct Answer: B

Rationale: The nurse's best response in this situation is to listen actively to the patient's concerns, acknowledge the inconvenience they are experiencing, and offer support. It is essential to validate the patient's feelings and show empathy towards their frustration. By actively listening and addressing the patient's concerns, the nurse can help alleviate some of their frustration and build a positive rapport with the patient. This approach demonstrates respect for the patient's feelings and promotes effective communication in the healthcare setting. Dismissing or ignoring the patient's frustration can lead to further dissatisfaction and impact the quality of care provided.

Question 8 of 9

A postpartum client presents with calf pain, swelling, and warmth. Which nursing action is most appropriate?

Correct Answer: C

Rationale: The most appropriate nursing action in this scenario is to notify the healthcare provider immediately. The client's presentation of calf pain, swelling, and warmth could be indicative of a deep vein thrombosis (DVT), which is a serious condition that requires prompt evaluation and intervention by the healthcare provider. DVT is a blood clot that forms in a deep vein, often in the leg, and if left untreated, it can lead to life-threatening complications such as pulmonary embolism. Therefore, timely communication with the healthcare provider is critical to ensure that the client receives the appropriate diagnostic testing and treatment to address the potential DVT. Applying warm compresses, encouraging ambulation, or administering NSAIDs would not be the first-line interventions for a suspected DVT and may even worsen the condition.

Question 9 of 9

The type of incontinence Patient Tita manifests, where there is involuntary loss of urine as a result of sneezing, coughing or even changing position is called ________.

Correct Answer: B

Rationale: The type of incontinence that Patient Tita is demonstrating, with involuntary loss of urine occurring as a result of activities such as sneezing, coughing, or changing position, is known as stress incontinence. Stress incontinence occurs when there is increased pressure on the bladder, causing the sphincter muscles to weaken and leading to urine leakage. Activities that physically stress or put pressure on the bladder, such as the ones mentioned, can trigger episodes of stress incontinence.

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