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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Deep tendon reflexes 2+: Deep tendon reflexes are typically assessed to monitor for signs of magnesium sulfate toxicity. A normal finding of 2+ deep tendon reflexes suggests that the client is not experiencing magnesium sulfate toxicity. However, it does not specifically indicate whether the medication is at a therapeutic level.

B. Respiratory rate of 10 breaths/minute: A respiratory rate of 10 breaths/minute is below the normal range, and it could indicate respiratory depression, a potential side effect of magnesium sulfate toxicity. While this finding suggests a potential adverse reaction to the medication, it does not confirm whether the medication is at a therapeutic level.

C. Urinary output of 20 mL per hour: Adequate urinary output is essential for excreting magnesium sulfate and preventing toxicity. A urinary output of 20 mL per hour is within an acceptable range and suggests adequate renal function, which is important for maintaining therapeutic levels of the medication. However, it alone does not confirm whether the medication is at a therapeutic level.

D. Difficulty in arousing: Difficulty in arousing is a concerning sign of magnesium sulfate toxicity and suggests central nervous system depression. It indicates that the client may be experiencing an adverse reaction to the medication and that the dose may need adjustment. While this finding suggests a potential issue with medication dosing or toxicity, it does not confirm whether the medication is at a therapeutic level.

A. oligohydramnios B. preeclampsia C. chorioamnionitis D. post-term labor

Correct Answer is B

Explanation

A. Oligohydramnios:

Oligohydramnios refers to a condition where there is too little amniotic fluid surrounding the fetus in the womb. It can be concerning because amniotic fluid plays a crucial role in protecting and cushioning the fetus, aiding in lung development, and preventing compression of the umbilical cord. While oligohydramnios can be a complication in pregnancy, it's not necessarily more common or specific to twin pregnancies compared to singleton pregnancies.

B. Preeclampsia:

Preeclampsia is a serious pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, such as the liver and kidneys. It usually develops after 20 weeks of pregnancy and can lead to serious complications for both the mother and the babies if not managed properly. Multiple pregnancies, including twins, are considered a risk factor for developing preeclampsia. Therefore, pregnant women carrying twins require close monitoring for signs and symptoms of preeclampsia.

C. Chorioamnionitis:

Chorioamnionitis is an infection of the fetal membranes (chorion and amnion) and amniotic fluid. It typically occurs due to bacterial infection ascending from the vagina into the uterus, often during prolonged labor or rupture of membranes. While chorioamnionitis is a concern in pregnancy, it's not necessarily more common in twin pregnancies compared to singleton pregnancies.

D. Post-term labor:

Post-term labor refers to labor that begins after 42 weeks of gestation. Prolonged pregnancy beyond the due date can increase the risks of complications for both the mother and the baby, including fetal distress, macrosomia (large birth weight), and meconium aspiration. Post-term labor can occur in both singleton and multiple pregnancies, but it's not specifically more associated with twin pregnancies.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A woman pregnant with twins comes to the clinic for an evaluation. While assessing the client, the nurse would be especially alert for signs and symptoms for which potential problem?

Correct Answer is B

Explanation

After teaching a local woman's group about incontinence, the nurse determines that the teaching was successful when the group identifies which characteristic of stress incontinence?

A nurse is assessing a female client and suspects that the client may have endometrial polyps based on which clinical manifestation?

The nurse is presenting a class at a local community health center on violence during pregnancy. Which possible complication would the nurse include?

When performing a clinical breast examination, which would the nurse do first?

Which approach would be most appropriate when counseling a client who is a suspected victim of intimate partner violence?

A nurse is conducting a program for pregnant women with gestational diabetes about reducing complications. The nurse determines that the teaching was successful when the group identifies which factor as being most important in helping to reduce complications associated with pregnancy and diabetes?

A nurse is obtaining a medication history from a pregnant client with a history of systemic lupus erythematosus (SLE). Which medication(s) would the nurse expect the woman to report to be currently using? Select all that apply.

Assessment of a female client reveals a thick, white vaginal discharge. The client also reports intense itching and dyspareunia. Based on these findings, the nurse would suspect that the client has: