Nursing Elites

1. After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?

• A. maintaining adequate tissue perfusion
• B. demonstrating behaviors that reduce fears
• C. restored body integrity
• D. remaining free of infection

Correct answer: C

Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image. Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns. Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image. Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.

2. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?

• A. Risk for Self-Harm
• B. Body Image Disturbance
• C. Ineffective Role Performance
• D. Powerlessness

Correct answer: B

Rationale: The correct nursing diagnosis for this client is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and feeling incomplete due to infertility, which aligns with Body Image Disturbance. The statement does not directly indicate a risk for self-harm, so 'Risk for Self-Harm' is not the correct choice. 'Ineffective Role Performance' is not the best option as it does not address the client's primary concern regarding self-image. While 'Powerlessness' could be appropriate if the client expressed feelings of powerlessness related to infertility, it is not the most suitable diagnosis based on the given statement.

3. A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that which aspect of eye function is normal?

• A. Near vision
• B. Central vision
• C. Peripheral vision
• D. Ocular movements

Correct answer: D

Rationale: The correct answer is 'Ocular movements.' Moving the eyes through the six cardinal fields of gaze evaluates the function of the eye muscles, such as the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Normal movement in these fields indicates proper ocular movements. Near vision is assessed using a handheld vision screener, central vision with a Snellen chart, and peripheral vision through the confrontation test. Therefore, the evaluation of ocular movements through the six cardinal fields of gaze specifically assesses this aspect of eye function. Choices A, B, and C are incorrect as they pertain to different aspects of vision function that are evaluated using distinct assessment methods, not through the six cardinal fields of gaze.

4. A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is:

• A. Gravida 2, para 6
• B. Gravida 6, para 2
• C. Gravida 3, para 6
• D. Gravida 2, para 2

Correct answer: B

Rationale: The term gravida refers to the number of pregnancies, of any duration, that a woman has had. Parity (para) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Therefore, this client is gravida 6 (pregnant for the sixth time), para 2 (has a son and a daughter). In this case, the correct answer is Gravida 6, para 2. Choices A, C, and D are incorrect as they do not accurately reflect the information provided. Pregnancy outcomes are often described using the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (A), and live births (L). Applying this to the client's history, the GTPAL would be G = 6, T = 1, P = 1, A = 3, L = 2, which further confirms the correct answer.

5. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

• A. Provide her with copies of the approved dietary guidelines from the American Diabetes Association and the American Heart Association.
• B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
• C. Provide a high-protein diet plan for the client.
• D. Provide the client with information related to risk factors for heart disease and diabetes.

Correct answer: B

Rationale: The correct first step is to assess the client's current diet by asking her to provide a list of the types of foods she eats. This assessment will help the nurse determine a personalized dietary plan based on the guidelines from the American Diabetes Association and the American Heart Association. Providing the client with copies of the guidelines is important but not the initial action. A high-protein diet plan may not be suitable for all clients aiming to prevent heart disease and diabetes. While providing information on risk factors is important, it is not the primary step in assisting the client with determining a suitable diet for disease prevention.

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