A woman with polycystic ovary syndrome tells the nurse, "I hate this disease. Just look at me! I have no hair on the front of my head, but I've got hair on my chin and upper lip. I don't feel like a woman anymore." Further assessment reveals breast atrophy and increased muscle mass. Which nursing diagnosis would the nurse identify as the priority?

social isolation related to feelings about appearance

ineffective peripheral tissue perfusion related to effects of disease on vasculature

risk for suicide related to effects of condition and fluctuating hormone levels

situational low self-esteem related to masculinization effects of the disease

Answer and Explanation

The Correct Answer is D

A. Social isolation related to feelings about appearance:

Social isolation refers to a state in which an individual lacks social interaction or feels disconnected from others. This can occur when individuals feel self-conscious or ashamed about their appearance and may withdraw from social situations as a result. In this scenario, the woman's feelings about her appearance may indeed lead to social isolation. However, while social isolation is a significant concern, it may not be the most immediate priority compared to addressing the woman's feelings of low self-esteem.

B. Ineffective peripheral tissue perfusion related to effects of disease on vasculature:

Ineffective peripheral tissue perfusion refers to inadequate blood flow to the peripheral tissues, which can lead to impaired tissue oxygenation and nutritional deficits. While PCOS can have metabolic and cardiovascular implications, such as insulin resistance and dyslipidemia, leading to potential vascular issues, there is no indication in the scenario provided that the woman is experiencing acute vascular compromise. Therefore, this nursing diagnosis is less relevant in this context.

C. Risk for suicide related to effects of condition and fluctuating hormone levels:

PCOS is associated with an increased risk of mental health issues, including depression and anxiety, which can contribute to an elevated risk of suicidal ideation or behavior. The woman's distress over the physical manifestations of PCOS and feelings of diminished femininity could certainly exacerbate such psychological issues. However, while suicide risk is a serious concern, there is no explicit indication in the scenario that the woman is actively expressing suicidal thoughts or behaviors. Therefore, while it's important to monitor for signs of depression and suicidal ideation, this nursing diagnosis may not be the most immediate priority at this stage.

D. Situational low self-esteem related to masculinization effects of the disease:

This nursing diagnosis addresses the woman's feelings of low self-esteem specifically related to the physical manifestations of PCOS, such as hirsutism, alopecia, breast atrophy, and increased muscle mass, which are affecting her sense of femininity and self-identity. Given her distress and negative perception of her appearance, addressing her low self-esteem and providing support and interventions to help improve her self-image would likely be the most immediate priority in her care.

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Correct Answer is D

Explanation

A. Immunization:

Currently, there is no licensed vaccine available for the prevention of cytomegalovirus (CMV) infection. Therefore, immunization is not a viable option for preventing CMV infection during pregnancy. While researchers are actively working on developing a CMV vaccine, it is not yet available for widespread use.

B. Prenatal screening:

Prenatal screening for CMV is not routinely performed during prenatal care. Screening for CMV during pregnancy is not typically recommended unless there is a specific clinical indication, such as maternal symptoms suggestive of acute CMV infection or fetal abnormalities detected on ultrasound. Therefore, prenatal screening is not a primary preventive measure for CMV infection during pregnancy.

C. Antibody titer screening:

Antibody titer screening for CMV is also not routinely performed during prenatal care. While some healthcare providers may offer CMV antibody testing in certain situations, such as for women with a known exposure to CMV or those at increased risk of primary CMV infection during pregnancy, it is not a standard practice for all pregnant women. Therefore, antibody titer screening is not a primary preventive measure for CMV infection during pregnancy.

D. Frequent handwashing:

Frequent handwashing is the most important preventive measure for reducing the risk of CMV infection during pregnancy. CMV is commonly transmitted through close contact with bodily fluids, such as saliva, urine, blood, and genital secretions. Proper hand hygiene, including washing hands with soap and water for at least 20 seconds, especially after coming into contact with young children's saliva or urine, can help prevent the spread of CMV. This measure is crucial for pregnant women to reduce their risk of acquiring CMV and transmitting it to their unborn babies.

A. Have the technician come back later on. B. Notify the surgeon to obtain the specimen via a cut-down procedure. C. Tell the technician to obtain the specimen from the client's left arm. D. Stop the technician immediately.

Correct Answer is C

Explanation

A. Have the technician come back later on:

This option suggests delaying the blood draw until a later time when the IV line is removed or after the infusion is completed. While this may seem like a reasonable approach to avoid interfering with the IV line, it could lead to unnecessary delays in obtaining essential laboratory test results.

B. Notify the surgeon to obtain the specimen via a cut-down procedure:

This option involves a more invasive procedure, called a cut-down, which is typically reserved for situations where peripheral venous access is challenging or impossible. It involves making an incision to expose a vein for direct cannulation. This approach is not warranted in this scenario, where obtaining blood from the opposite arm is a standard and less invasive practice.

C. Tell the technician to obtain the specimen from the client's left arm:

This option is the most appropriate response. It instructs the technician to draw blood from the client's left arm, which is free from the IV line. Drawing blood from the opposite arm minimizes the risk of complications associated with interfering with the IV infusion.

D. Stop the technician immediately:

While stopping the technician immediately may prevent them from proceeding with the incorrect approach, it lacks specific guidance on how to proceed correctly. It's essential to provide clear instructions to the technician to draw blood from the opposite arm rather than simply halting the procedure without further direction.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing a teaching program for a group of pregnant women about preventing infections during pregnancy. When describing measures for preventing cytomegalovirus infection, which measure would the nurse include as a priority?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

The nurse is developing a plan of care for a client who is receiving aggressive drug therapy for treatment of HIV. The goal of this therapy is to:

A client who is HIV-positive is in her second trimester and remains asymptomatic. She voices concern about her newborn's risk for the infection. Which statement by the nurse would be most appropriate?

After teaching a group of adolescents about HIV, the nurse asks them to identify the primary means by which adolescents are exposed to the virus. The nurse determines that the teaching was successful when the group identifies which means of exposure?

During a clinical breast examination, the nurse palpates a well-defined, firm, mobile lump in a 60-year-old woman's left breast. The nurse notifies the primary care provider. What would the nurse anticipate the care provider to prescribe next?

A pregnant woman is diagnosed with chlamydia and asks the nurse, "How will this infection affect my baby and pregnancy?" Which responses by the nurse are accurate? (Select All that Apply.)

A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? (Select All that Apply.)

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?