Which nursing diagnosis applies to a client stating they feel incomplete due to infertility?

Correct Answer: B

Rationale: The correct answer is B: Body Image Disturbance. Infertility can impact one's perception of self and body image, leading to feelings of incompleteness. This nursing diagnosis addresses the emotional distress related to altered self-perception. A: Risk for Self Harm is not directly related to the client's statement about feeling incomplete due to infertility. C: Ineffective Role Performance doesn't specifically address the client's feelings of incompleteness related to infertility. D: Powerlessness may not fully capture the client's emotional struggle with their body image and feelings of incompleteness due to infertility.

Correct Answer: B

Rationale: The correct answer is B because the Set Test typically involves naming 10 items based on specific categories, such as those in the FACT acronym (Fruit, Animal, Color, and Town). The nurse should inform Mr. C. that he can complete the task without any hurry, which helps reduce stress and allows him to focus on recalling the items. This approach aligns with the standard administration procedure of the Set Test, promoting a relaxed and supportive environment for the patient. Choice A is incorrect because the nurse should not offer direct assistance or mention availability to help unless Mr. C. explicitly requests it. Choice C is incorrect as prompting the patient's memory may interfere with the natural cognitive process being assessed. Choice D is incorrect because imposing a time limit can induce unnecessary pressure and potentially affect the accuracy of the results.

Correct Answer: A

Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.

Correct Answer: B

Rationale: The correct answer is B: "Is there anything else you would like to mention?" This question allows the patient to share any additional information or concerns before concluding the interview. It shows empathy and ensures thorough communication. Choice A is not the best option as it may suggest the nurse is rushing or has overlooked something. Choice C is inappropriate as it lacks empathy and may make the patient feel rushed. Choice D is also incorrect as it shifts the focus to a different topic instead of allowing the patient to express any remaining issues or questions.

Correct Answer: C

Rationale: The correct answer is C: Severity. In the PQRSTU mnemonic, "S" stands for Severity, which refers to the intensity or seriousness of the symptoms experienced by the patient. This is crucial in assessing the impact of the problem on the patient's health and well-being. Incorrect choices: A: Swelling - Swelling is a physical symptom and does not encompass all aspects of the patient's perception. B: Subjectivity - While the patient's subjective experience is important, it does not specifically refer to severity. D: Symptoms - While symptoms are part of the patient's perception, the "S" in PQRSTU specifically focuses on the severity of those symptoms.

Correct Answer: B

Rationale: The correct answer is B: Encourage fluid intake. Adequate hydration helps in pain management by promoting circulation and reducing inflammation. Opioids (choice A) should only be used if non-pharmacological interventions fail. Administering oxygen (choice C) is not typically indicated for pain management. Monitoring electrolyte levels (choice D) is important but not the most immediate intervention for acute pain post-surgery.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When a client presents with symptoms of hypoglycemia, the nurse should prioritize raising the blood sugar levels immediately to prevent further complications. Administering glucose helps to quickly address the low blood sugar levels and alleviate symptoms. Monitoring blood glucose (B) is important but not the first step in an acute situation. Administering insulin (C) would worsen hypoglycemia. Monitoring for arrhythmias (D) is not the primary concern when dealing with hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A because it focuses on prioritizing the assessment by first addressing the immediate problem of shortness of breath. By examining only the body areas related to the current issue, the nurse can quickly gather essential information to manage the patient's respiratory distress effectively. Once the critical issue is stabilized, a complete assessment can be conducted to identify any underlying problems or potential complications. This approach ensures that the nurse addresses the most urgent needs first before proceeding to a comprehensive assessment. Choice B is incorrect because it suggests only examining body areas directly related to the hospitalization problem, which may overlook other critical issues contributing to the shortness of breath. Choice C is incorrect as shortness of breath is not a normal finding and should not be dismissed without further evaluation. Choice D is incorrect as examining the entire body without focusing on the immediate issue may delay appropriate interventions for the patient's respiratory distress.

Correct Answer: C

Rationale: The correct answer is C because stopping insulin when blood sugar is normal can lead to hyperglycemia. Choice A shows understanding of managing diabetes. Choice B indicates monitoring blood sugar, crucial for diabetes management. Choice D demonstrates adherence to medication schedule, essential for controlling blood sugar levels. Stopping insulin prematurely can disrupt the balance and result in complications.