A client in an alcohol rehabilitation program tells the nurse "I've been such a loser all my life! I feel so ashamed for what I have put my family through! Now I am in rehab and I am not sure I can stay sober."
What nursing diagnosis would be most appropriate? A) High risk for violence
B) Self-esteem disturbance
C) Alteration in health maintenance
D) Powerlessness
B
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An expected nursing intervention for a patient diagnosed with Bell's palsy would be which of the following?
A) Applying a protective eye shield B) Encouraging the patient to eat on the affected side C) Avoiding analgesics D) Avoiding brushing of the teeth
The emergency department (ED) team is conducting immediate care of a patient admitted with burns estimated at 40% total body surface area
The nurse in the ED and the other members of the team are aware of the need to customize the rate of fluid resuscitation and will base this rate on what data? A) Level of consciousness and pain levels B) Abdominal girth measurements and abdominal tone C) Vital signs and urine output D) Arterial blood gases and breath sounds
An older client lives in an assisted living facility and is seen reading in the lounge area most nights. Which issue causes the greatest concern for the nurse caring for this client?
1. The client may have significant underlying problems. 2. The client is averaging five hours of sleep every 24 hours. 3. The client occasionally expresses the desire for more sleep. 4. The client is forgetful, irritable, and frequently lethargic.
A nurse is caring for a client who is receiving dialysis. An order on the client's chart reads "Guaiac all stools." What should the nurse do?
A) Monitor all stools for consistency and color. B) Measure all stools to monitor the output. C) Send all stools for occult blood test. D) Send all stools for a culture and sensitivity test.