The elderly wife of a hospice client has reported experiencing difficulty sleeping, and a decreased appetite. The priority nursing diagnosis most likely to apply is
1. Grieving
2. Fear
3. Risk for Caregiver Role Strain
4. Interrupted family process
3
Rationale: The client may be grieving, however this is not the priority diagnosis.
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A nurse serving the community in a public health role would likely perform which of the following functions within a particular community?
a. Tracking the prevalence of gonorrhea between January and June b. Screening for scoliosis among 12- to 14-year-old girls in middle school c. Weighing premature infants receiving phototherapy at home d. Giving the H1N1 vaccine to fire and police personnel
The nurse educator is teaching a group of nursing students how to perform an assessment of the client's peripheral vascular system. Which student statements indicate an appropriate understanding of the peripheral vascular assessment? Select all that apply
1. "I need to take a blood pressure only in the client's right arm." 2. "The best way to assess the carotid pulses is palpate one side and then the other." 3. "It will be easier to assess the client's carotid pulses if the client is obese." 4. "I should inspect the arms to ensure that they are close to the same size." 5. "I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions."
A nurse is caring for a patient with acute myeloid leukemia (AML) who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the nurse should assign the highest priority to which nursing diagnoses?
A) Activity intolerance B) Risk for infection C) Ineffective coping D) Risk for spiritual distress
A client is admitted to the hospital with a diagnosis of kidney stones. The physician orders IV fluids, x-rays, blood work, and a Foley catheter for the client
The nurse is caring for the client 3 days after admission and takes morning vital signs of 101°F, heart rate 92, respirations 25, and blood pressure 120/80. The urinary output has decreased, and the urine is cloudy and dark amber. The nurse suspects which of the following? 1. The client is getting ready to pass the kidney stones. 2. The client has developed a cold. 3. The client has a urinary tract infection that is probably nosocomial. 4. The client is in renal failure.