Which nursing model defines nursing diagnosis as a "judgment process resulting in a statement conveying the person's adaptation status?"
a. Roy c. Orem
b. Neuman d. Selye
A
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The client assessment finding that deserves priority intervention by the nurse working in the
community setting is that the client a. receives Social Security disability income plus a small check from a trust fund. b. lives in an apartment with two clients who attend day hospital programs. c. has a sister who is interested and active in his care planning. d. purchases and uses marijuana on a frequent basis.
A nurse is preparing to administer two drugs at the same time to a client via a double-lumen midline catheter. Which action by the nurse is most important?
a. Check the two drugs for compatibility. b. Compare the recommended infusion times. c. Schedule any post-infusion lab draws. d. Flush both lumens with saline before starting the infusion.
Escharotomies have been performed on a patient's arms because of circumferential burn injuries. What is the nurse's highest assessment priority?
1. Circulation in the extremity distal to the escharotomy 2. Formation of contractures 3. Wound infection in the escharotomy site 4. Ability to perform range-of-motion exercises
A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychological evaluation. The nurse's best initial response is to
a. refer the child to a psychologist immediately. b. explain that playing make believe is normal at this age. c. complete a developmental screening using a validated tool. d. separate the child from the mother to get more information.