Which diagnosis is most appropriate for the nurse to select for a patient with Behçet syndrome?
a. Activity intolerance, related to unsteady gait
b. Risk for injury, related to falls
c. Imbalance in nutrition: Less than body requirements, related to anorexia
d. Sexual dysfunction, related to pain in ge-nital area
D
Pain from the genital ulcers interferes with sexual expression.
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The nurse is able to indent the skin on the dorsal surface of the foot 4 mm while palpating pedal pulses. The nurse documents this assessment as
A) nonpitting edema. B) 2+ pitting edema. C) 3+ pitting edema. D) 4+ pitting edema.
While rock climbing, a 22-year-old male has endured a severe head injury
Which of the following statements best captures expected clinical manifestations and treatments for his immediate condition? A) Oxygen therapy is likely to decrease his respiratory drive and produce an increase in PCO2. B) Cheyne-Stokes breathing is likely but will respond to bronchodilators. C) The client is unlikely to respond to supplementary oxygen therapy due to impaired diffusion. D) Hypoventilation may exist, resulting in increased PCO2 and hypoxemia that may require mechanical ventilation.
A client has a breast tumor 3 centimeters in diameter, with no lymph nodes involved or metastases evident. The client's cancer would be considered to be in which stage?
a. I c. III b. II d. IV
A nurse is observing the progress of an elderly client started on a new medication for dementia
Which is a critical point for the nurse to consider when collecting subjective data about the client and the response to the new medication for dementia? A) Assess the client's body language and nonverbal gestures. B) Disregard the presence of a cross that the client continuously holds. C) Avoid asking the client any direct questions because of the dementia. D) Request that a family member be present during the assessment.