A nurse is caring for a visually impaired 20-month-old who has not begun to walk. Which nursing diagnosis would be appropriate for this child?
1. Self-care deficit
2. Impaired physical mobility
3. Impaired home maintenance
4. Delayed growth and development
4
Rationale 1: Self-care deficit does not apply to this age of child.
Rationale 2: The child's mobility is not due to a physiological problem, so impaired mobility is not appropriate.
Rationale 3: There are not enough data to determine if home maintenance is impaired.
Rationale 4: A 20-month-old child who is not walking is delayed in growth and development. Toddlers generally walk by 15 months of age.
Global
You might also like to view...
In the review of literature, the nurse researcher was unable to find a questionnaire to collect the unique data required for the proposed study. The researcher developed a questionnaire specifically for the study
Once the study began, the researcher discovered that the questionnaire was not supplying the data necessary to answer the study question. How could the researcher have best avoided this situation? 1. Used a preexisting questionnaire, even though it did not collect the correct data. 2. Requested that another nurse read the questionnaire. 3. Done a pilot study with the questionnaire. 4. Altered the questionnaire after data collection started.
Which of the following instructions should a nurse provide a client with a respiratory infection?
A) Avoid intake of frozen foods. B) Avoid visiting older adults. C) Avoid direct sunlight. D) Avoid meats and other protein-rich foods.
The family of a client with chronic gallbladder inflammation and obstructive jaundice asks why the client's skin is itchy. What is the nurse's best response?
A. "Bile salts accumulate on the skin causing it to itch." B. "Liver failure is imminent when metabolic products appear on the skin." C. "The bacteria responsible for inflammation of the gallbladder produce toxins on the skin." D. "The itching is caused by the breakdown of gallstones, which causes a hypersen-sitivity response."
The nurse measures weight daily for an assigned client and finds that the client gained 4 pounds in one day. The nurse interprets that this weight increase is most likely due to greater:
1. protein intake. 2. carbohydrate intake. 3. fat intake. 4. fluid intake.