A patient who has a history of bipolar disorder recently underwent orthopedic surgery and was discharged to return home
When visited by the home care nurse, the nurse documented the following: slow and soft speech; sad facial expression; and patient crying when describing extreme fatigue, low mood, and the feeling that he will never get well. He has refused to bathe and perform ADLs for several days. Which nursing diagnosis would be appropriate?
a. Self-care deficit secondary to possible depression
b. Situational low self-esteem related to immobility
c. Deficient knowledge related to depression and surgery
d. Disturbed thought processes related to bipolar disorder
ANS: A
Refusal to perform tasks of bathing, grooming, and other ADLs provides evidence of a self-care deficit. The other symptoms documented by the nurse are characteristic of depres-sion. No data are present to suggest the diagnoses given in the other options.
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While listening over the manubrium, the nurse auscultates loud expiratory sounds that last longer than inspiratory sounds. The nurse will document her findings as: A) Vesicular breath sounds B) Bronchovesicular breath sounds C) Bronchial breath sounds D) Tracheal breath sounds
The alarm of a patient's infusion delivery system is sounding. The nurse should assess for which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Air in the line 2. Occlusion of the tubing 3. Infusion complete 4. Wrong fluid being infused 5. Free flow
The first step in the process of evaluation is
a. collecting data b. judging the value of nursing interventions c. establishing standards d. determining goal achievement
The nurse completes postoperative discharge teaching to the parents of a child who had a tonsillectomy. Which statement by the parents indicates correct understanding of the teaching session?
1. "We will call the physician for any indication of ear pain." 2. "We will plan on administering acetaminophen (Tylenol) for pain." 3. "We will be sure to give our child adequate amounts of citrus juices." 4. "We will keep our child on bed rest for 10 days after the surgery."