A client tells the nurse that "I'm told that I should reduce the stress in my life, but I have no real idea
what things create stress for me and no idea of where to start.".
The nursing diagnosis the nurse
should consider for this client is
a. ineffective coping.
b. defensive coping.
c. decisional conflict.
d. ineffective denial.
ANS: A
Only Option A relates to the data given. The definition of this nursing diagnosis is the inability to
form a valid appraisal of the stressors, inadequate choices of practiced responses, or inability to use
available resources. Option B: Defensive coping involves projection of a falsely positive
self-evaluation based on a self-protective pattern that defends against underlying perceived threats to
positive self-regard. Option C: Decisional conflict speaks to uncertainty about the course of action to
be taken when the choice among competing actions involves risk, loss, or challenge to personal life
values. Option D: Ineffective denial suggests attempts to disavow the knowledge or meaning of an
event to reduce anxiety, which lead to the detriment of health.
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When assessing a patient with hypophosphatemia, the nurse should keep in mind that the clinical manifestations of this disorder correlate with those of:
A) hypercalcemia. B) hypocalcemia. C) hypermagnesemia. D) hypomagnesemia.
Which cardiac complication does the nurse anticipate in the patient with advanced COPD?
A) Cor pulmonale B) Left-sided heart failure C) Pericarditis D) Hypertension
The client is receiving oral anticoagulant therapy with warfarin (Coumadin). The result of a newly drawn prothrombin time (PT) is 40 seconds. The nurse anticipates carrying out a prescription to do which of the following?
1. Hold the next dose of warfarin. 2. Increase the next dose of warfarin. 3. Administer the next dose of warfarin. 4. Stop the warfarin, and administer heparin.
A client has come to the health care provider's office with symptoms of a urinary tract infection (UTI). She states that she had no symptoms when she went to bed last night but woke this morning with severe burning with urination
A urine culture is completed and grows Escherichia coli. The client asks the nurse why these symptoms occurred so suddenly. The nurse's best response is: 1. "You probably had the symptoms for some time, but you didn't notice it until it became severe." 2. "The severity of your symptoms indicates a hygiene problem." 3. "Do you often have complaints of severe pain when you awaken?" 4. "The bacteria that caused your infection grow very rapidly, so it is possible you had no symptoms the night before."