After several doses of chemotherapy, a patient complains of fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia. Which NANDA nursing diagnosis would the nurse list as the first priority?
1. Imbalanced Nutrition: Less than Body Requirements
2. Activity Intolerance
3. Powerlessness
4. Ineffective Coping
2
Rationale 1: Nutrition or iron deficiency is not the likely cause of these symptoms.
Rationale 2: The symptoms indicate that the patient is not tolerant of activity, probably because of the bone marrow depression from chemotherapy and the resulting decrease in RBC production.
Rationale 3: Powerlessness is the lack of control over current situations, but this is not the patient's current problem.
Rationale 4: Although the patient might have coping issues, the physical symptoms are the greatest complaints; therefore, coping is not the top priority in planning care. Physiological needs must be met prior to self-actualization needs.
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An ICU unit has experienced an influx of aggressive behaviors by visitors against nurses The ICU manager has instituted a policy to limit visiting hours. An employee asks the manager why the change in visiting hours has been implemented
Which response is likely the most accurate? 1. "The unit has been so busy, I must allow for the nurses to have time to provide client care." 2. "The visitor hours have not been adjusted in years. It was time to change them." 3. "The physicians have requested limited visiting hours." 4. "The visiting hours allowed for added stress and commotion to the nursing staff."
During a home care visit, the patient experiences an angry outburst and hits the nurse on the thigh and yells at her. The patient continues to be threatening. What are the appropriate initial actions by the nurse? (Select all that apply.)
a. Call for a family member who lives down the street. b. Call law enforcement to take the patient to the hospital. c. Tie the patient to the bed. d. Yell at the patient to stop being threaten-ing. e. Call the nursing agency. f. Use a calm, quiet voice when talking with the patient.
At what point during hospital-based care does planning for discharge begin?
A) on admission to the hospital C) immediately before discharge B) after the patient is settled in a room D) after leaving the hospital