Despite the fact that the patient is 5'6" and weighs 72 lbs, the patient reported feeling "fat and overweight." What is the most appropriate nursing diagnosis for this patient?
1. Chronic Low Self-Esteem
2. Ineffective Coping
3. Altered Nutrition
4. Body Image Disturbance
4
Rationale: Clients with anorexia nervosa are unable to make realistic appraisal of their own body size, although they can accurately evaluate the size of others. They drastically overestimate their own body size. Altered Nutrition, Low Self-Esteem, and Ineffective Coping are not appropriate diagnoses.
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A 35-year-old woman is diagnosed with stage III breast cancer. She seems to be extremely anxious. What action by the nurse is best?
a. Encourage the client to search the Internet for information tonight. b. Ask the client if sexuality has been a problem with her partner. c. Explore the idea of a referral to a breast cancer support group. d. Assess whether there has been any mental illness in her past.
A 57-year-old CEO of a large corporation has complaints of rectal bleeding and occasional lower abdominal pain. The patient may have which of the following?
A) Ulcer B) Crohn's disease C) Rectal polyps D) Inflammatory bowel disease
A mother with diabetes has done some reading about the effects of her condition on newborns. Which of the following statements shows a misunderstanding that should be clarified by the nurse?
a. "Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be." b. "My baby will be watched closely for signs of low blood sugar, especially during the early days after birth." c. "The red appearance of my baby's skin is due to an excessive number of red blood cells." d. "My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy."
The nurse is preparing to assess a patient's integumentary status. What should the nurse do prior to beginning this examination?
Select all that apply. 1. Obtain a gown and drape for the patient 2. Cleanse the blood pressure cuff with alcohol 3. Obtain several pairs of disposable gloves 4. Ensure the examination room is warm and private 5. Place a ruler and flashlight near the examination table