The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?
A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness during hospital stay
C. Client will state pain relieved within 30 minutes after medication
D. Pressure will be prevented by repositioning client every 2 hours
Ans: B. Skin will remain intact and without redness during hospital stay
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The patient is in hypovolemic shock from traumatic massive blood loss and is tachypneic and tachycardic, with cool, clammy skin and weak and thready pulses
What additional assessment parameter would the nurse be least likely to find during stage one or early compensated shock? A) Hypotension B) Increased urine output C) Estimated blood loss greater than 30% D) Mild altered mental status
A patient with a terminal illness confides in his nurse that he plans to commit suicide. The nurse struggles with whether to report his intent
In the "Code of Ethics for Nurses" of the American Nurses Association, the nurse reads the following statement: "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.". In this case, the nurse perceives the greatest ethical conflict between: A) Advocacy and protection B) Safety and patient rights C) Health and terminal illness D) The patient and the nurse
A patient with a diagnosis of primary adrenal hypertrophy is postoperative day 1 following a unilateral adrenalectomy
The nurse's astute assessment of the patient has revealed the presence of signs and symptoms that are typically associated with adrenal insufficiency. How should the nurse follow-up these assessment findings? A) Reassure the patient that these changes are a normal, temporary response to the removal of the adrenal glands. B) Contact the care provider because steroid replacement therapy may be temporarily needed. C) Document the assessment findings and reassess in 1 to 2 hours. D) Administer a p.r.n. dose of IV calcium gluconate.
A client tells the nurse that he has been meditating for several months and has noticed a reduction in stress and blood pressure. The nurse knows that meditating can also:
a. improve immune system functioning. b. increase oxygen consumption. c. raise the heart rate. d. raise the blood pressure.