Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?

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Question 1 of 5

Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?

Correct Answer: D

Rationale: Option D is the most appropriate statement when assisting a patient with altered thought process and personal hygiene needs. This statement provides the patient with a choice between brushing their teeth independently or having assistance, while also emphasizing the importance of self-care activities. Offering patients choices empowers them and helps maintain their sense of autonomy, even when dealing with altered thought processes. Additionally, encouraging patients to perform activities for themselves can help improve their self-esteem and promote independence.

Question 2 of 5

The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this newborn?

Correct Answer: D

Rationale: Hypospadias is a congenital condition where the opening of the urethra is located on the ventral surface of the penis instead of the tip. This results in the ventral placement of the urethral meatus compared to the normal dorsal position. It can typically be visually identified when examining the newborn's genitalia. A key characteristic of hypospadias is the abnormal positioning of the urethral opening, which distinguishes it from other conditions affecting the male genitalia.

Question 3 of 5

Why place an undershirt between the skin and the Pavlik harness?

Correct Answer: C

Rationale: Placing an undershirt between the skin and the Pavlik harness is done to prevent skin abrasions and irritation caused by the harness rubbing directly against the skin. The undershirt acts as a protective layer, reducing the likelihood of skin sensitivity or damage due to the continuous contact with the harness. This is particularly important for infants or young children who may have delicate skin that is more prone to irritation. By using an undershirt, caregivers can help ensure greater comfort for the child while wearing the Pavlik harness and reduce the risk of any skin-related complications.

Question 4 of 5

A patient with a new diagnosis of lung cancer decides to have radiation therapy. Which of the ff. expectations of this treatment is most appropriate?

Correct Answer: C

Rationale: Radiation therapy for lung cancer is typically used with the goal of increasing comfort for the patient by reducing symptoms such as pain, shortness of breath, and coughing. While it may help to shrink tumors and slow the progression of the disease, it is usually not considered a curative treatment for advanced lung cancer. It is important for the patient to have realistic expectations and understand that the goal of radiation therapy is primarily to improve their quality of life and manage symptoms.

Question 5 of 5

The client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis?

Correct Answer: D

Rationale: Edrophonium (Tensilon) is a short-acting cholinesterase inhibitor used in the Tensilon test to aid in the diagnosis of myasthenia gravis. In patients with myasthenia gravis, there is a deficiency of acetylcholine at the neuromuscular junction, leading to muscle weakness. By inhibiting the breakdown of acetylcholine, edrophonium temporarily increases the availability of acetylcholine at the neuromuscular junction.

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