The nurse is caring for a client who is hospitalized due to an exacerbation of systemic lupus erythematosus (SLE). The nurse is reviewing the client's lab work and finds the white blood cell count (WBC) is shifted to the left
Based on this information, which is a priority nursing diagnosis for this client?
A) Risk for Infection
B) Ineffective Health Maintenance
C) Ineffective Individual Coping
D) Risk for Impaired Skin Integrity
Answer: A
All identified diagnoses are appropriate for a client with SLE. However, the shift to the left in the WBC count indicates an increased risk for infection. A shift to the left in a WBC differential is indicative of a large number of immature cells, suggesting infection. Therefore, the priority diagnosis is Risk for Infection.
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To ensure the success of a proposed community intervention program, the community health nurse would include which of the following?
A) Formal leaders B) Advisory group C) Target population D) Local knowledge
The nurse determines that a patient is in the process of acculturation. What did the nurse assess in this patient?
A. Americanization of the patient's name B. Engaging in activities with members of the family's preferred social group C. Speaking the family's native language D. Living away from the family of origin
The nurse emphasizes that a toddler younger than the age of 18 months should never be spanked primarily for which reason?
A) Spanking in a child this age predisposes the child to a pro-violence attitude. B) The child will become resentful and angry, leading to more outbursts. C) Spanking demonstrates a poor model for problem-solving skills. D) There is an increased risk for physical injury in this age group.
The health status of an older patient with liver disease is rapidly deteriorating. There is no documentation on the medical record regarding the patient's care wishes. What should the nurse do to ensure the patient receives care that is desired at the end of life?
1. Ask social services to provide an advance directive for the patient to complete. 2. Talk with the patient regarding what the patient wants after the hospitalization ends. 3. Call a meeting with the patient, family, and primary care physician to discuss care goals. 4. Discuss the patient's dire situation with the family and find out what their wishes might be.