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. Flaky, peeling skin (desquamation) occurs in later stages of scarlet fever, typically after the rash begins to fade. It is not an early sign of the disease.
B. A red, sandpaper-like rash that typically begins on the chest and spreads outward is one of the earliest indications of scarlet fever. This rash is caused by exotoxins produced by Streptococcus pyogenes and is a hallmark sign of the illness.
C. A white coating on the tongue, often followed by a characteristic “strawberry tongue,” develops later in the progression of scarlet fever rather than as an early symptom.
D. While fever is a common symptom of streptococcal infections, it is not the earliest indicator of scarlet fever. The rash usually appears within 12 to 48 hours of fever onset, making it a more specific early sign.
Correct Answer is ["B","D","E"]
Explanation
A. While managing pain is important, the client did not report significant pain, making it a lower priority in this scenario.
B. Quitting smoking is crucial for the client's respiratory health, especially given the history of smoking and current respiratory symptoms.
C. There is no indication that the client is at risk of skin breakdown; thus, it is not a priority in the immediate discharge plan.
D. Maintaining an oxygen saturation of 96% without supplemental oxygen is a direct indicator of improved respiratory function and a key goal for discharge.
E. Being afebrile for 24 hours would indicate that the infection is under control, which is a primary concern for discharge after presenting with flu-like symptoms.
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