The nurse has chosen these nursing diagnoses for a patient who has systemic lupus erythematosus. Which NDX would be assigned the highest priority?
1. Skin Integrity: Impaired
2. Activity Intolerance
3. Anxiety
4. Fluid Volume Excess
2
Rationale 1: Impaired Skin Integrity is applicable to most patients with SLE, but this is not the NDX of highest priority.
Rationale 2: Inability to tolerate activity is the highest priority of the NDX listed. Patients should be taught to balance rest and activity.
Rationale 3: The patient with SLE is likely to be anxious about the disease process and its effect on daily life. This is not the NDX of highest priority.
Rationale 4: The patient with SLE may have fluid volume problems if kidney function is impaired. This is not the NDX of highest priority.
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A patient with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use is prescribed misoprostol (Cytotec). The nurse would be most accurate in informing the patient that the drug:
A) Reduces the stomach's volume of hydrochloric acid B) Increases the speed of gastric emptying C) Protects the stomach's lining D) Increases lower esophageal sphincter pressure
A nurse is preparing to administer spironolactone to a client. The nurse would contact the primary health care provider about the need to change the order if the client has a history of which of the following?
A) Hyperkalemia B) Liver disease C) Gout D) Diabetes
What should the nurse recognize when comparing the physical changes in young and middle adulthood?
a. Fertility issues do not occur in young adulthood. b. Young adults are quite active but are at risk for illness in later years. c. Young adults tend to suffer more from severe illness. d. Exercise is less important in young adulthood than in middle adulthood.
When giving CPR to an infant, about how deep should you compress the chest:
a. About ½ inch b. About 1 inch c. About 1½ inches d. About 2 inches