Which nursing diagnosis should a nurse identify as being correctly formulated?
A. Schizophrenia R/T biochemical alterations AEB altered thought
B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance
C. Depressed mood R/T multiple life stressors
D. Developmental disability R/T early-onset schizophrenia AEB hallucinations
B
The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the unhealthy response (inference), the contributing factors, and the data that support the inference.
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After administering 40 mEq of potassium chloride, a nurse evaluates the client's response. Which manifestations indicate that treatment is improving the client's hypokalemia? (Select all that apply.)
a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)
Which is nutrient is considered to be MOST important to the body?
a. calcium c. protein b. oxygen d. water
A nurse is using an IV port when administering medication to a client. Which of the following methods of IV administration has the greatest potential to cause life-threatening changes?
A) Bolus administration B) Electronic infusion C) Continuous administration D) Secondary administration
The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction
Which collaborative action would be appropriate for this client? 1. Provide a calm, quiet atmosphere in the client's room. 2. Administer pain medication. 3. Educate the client and family regarding treatment and therapies. 4. Monitor for changes in the client's condition.