A 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?
Ineffective coping related to denial
Decisional conflict due to stress
Deficient knowledge of lifestyle changes
Anxiety related to treatment plan.
The Correct Answer is A
A. The client's desire to go home so soon after a significant medical event like an MI suggests a possible denial of the severity of his condition and an unwillingness to acknowledge the
need for further medical care and recovery time.
B. While decisional conflict due to stress could be a concern, the client's behavior does not directly indicate stress about making decisions, but rather a disregard for the gravity of his recent health event.
C. Deficient knowledge of lifestyle changes is likely an issue for someone who has just experienced an MI, but the immediate behavior of wanting to leave the hospital does not directly relate to a lack of knowledge about necessary lifestyle changes.
D. Anxiety related to the treatment plan could be present, but the client's behavior of wanting to leave the hospital suggests a coping mechanism of denial rather than anxiety about the treatment itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Marking an outline of the "olive-shaped mass" in the right epigastric area is important for diagnosis, but not a priority pre-operatively.
B. Initiating a continuous infusion of IV fluids is crucial to ensure the infant is properly hydrated before the procedure, as pyloric stenosis can cause severe dehydration.
C. Monitoring the amount of intake and the infant's response to feedings is part of ongoing care, but immediate pre-operative hydration takes precedence.
D. Instructing parents regarding care of the incisional area is necessary post-operatively, not before the surgery.
Correct Answer is ["B","D","E"]
Explanation
A. A diet low in phosphorus is not typically indicated for cirrhosis of the liver. Cirrhosis primarily affects the body's ability to handle proteins and not phosphorus.
B. Noting signs of swelling and edema is important as these are common complications of cirrhosis due to hypoalbuminemia and portal hypertension.
C. Increasing oral fluid intake is not advised as it can exacerbate fluid retention and ascites, which are complications of cirrhosis.
D. Monitoring abdominal girth is crucial for assessing changes in ascites and potential fluid overload.
E. Reporting serum albumin and globulin levels is essential as these can indicate the severity of liver disease and help guide treatment.
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