The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD) who has a breathing rate of 32 per minutes, elevated blood pressure, and fatigue
Which nursing diagnosis is the priority for this client?
A) Ineffective Coping
B) Ineffective Airway Clearance
C) Anxiety
D) Ineffective Breathing Pattern
Answer: D
The client's respiratory rate of 32 per minute is an indication of an ineffective breathing pattern. The elevated blood pressure and fatigue are indications of a compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would be the priority for the client at this time. There is no information to support Ineffective Airway Clearance, as there is no mention that the client is coughing. There is no information to support Anxiety or Ineffective Coping.
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During a health history interview the nurse becomes concerned that a patient is at risk for a genetic hearing disorder. On what information did the nurse base this clinical decision?
Select all that apply. 1. The patient's mother, age 76, uses hearing aids. 2. The patient's father had tubes in the ears as a child. 3. The patient's brother lost his hearing because of a thyroid disorder. 4. The patient's sister was treated for ear drainage after swimming. 5. The patient's nephew had surgery to remove a tumor on the acoustic nerve.
A 31-year-old woman is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the health care provider about the methotrexate?
a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.
The nurse is caring for a 6-year-old boy diagnosed with mumps. Which of the following teaching points would be appropriate for the parents of this client?
A) "Protect your other children from close contact with your son." B) "The swelling should disappear within a week." C) "The disease may cause sterility in your child." D) "Your son will need IV antibiotics to cure the disease."
Before obtaining a clean-catch urine specimen, you must first be sure that
A. You throw away the first 30 cc of urine that the patient voids. B. The perineal area is cleansed with soap and water or antiseptic towelettes. C. The patient drinks 24 ounces of fruit juice or water. D. The specimen container has been placed in a pan of ice.