A nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses will are most likely to relate this patient's care? (Select all that apply.)
a. Imbalanced nutrition, more than body requirements
b. Disturbed thought processes
c. Disturbed sleep pattern
d. Chronic confusion
e. Social isolation
B, C
Persons with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Psychosis may occur. Confusion may be acute but not chronic.
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When visiting a local senior center, a community health nurse engages several of the older adults in a discussion about immunizations. Which statement best reflects the importance of older adult immunization?
A) "We're at greater risk of dying from the flu or pneumonia." B) "You don't get the flu from the flu shot." C) "The doctor told us that we should get it." D) "Many of us get the shot here at the center for free."
What should a nurse advise the parents of a child with type 1 diabetes mellitus who is not eating as a result of a minor illness?
a. Give the child half his regular morning dose of insulin. b. Substitute simple carbohydrates or calorie-containing liquids for solid foods. c. Give the child plenty of unsweetened, clear liquids to prevent dehydration. d. Take the child directly to the emergency department.
The nurse planning care for a client newly diagnosed with elevated serum cholesterol, triglycerides, and LDL initiates a dietary consult for which reason?
1. This particular pattern of dyslipidemia is not amenable to pharmacological agents. 2. Nonpharmacologic approaches to dyslipidemia should be initiated before pharmacologic agents are prescribed. 3. These levels are sufficiently high that pharmacologic intervention alone is unlikely to be successful. 4. Dietary modifications can be useful for lipid disorders, but only as an adjunct intervention after pharmacologic therapy for clients has been initiated.
A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?
a. Decreased cardiac output related to altered myocardial contractility. b. Patient needs a low-fat diet related to inadequate heart perfusion. c. Offer a low-fat diet because of heart problems. d. Acute heart pain related to discomfort.