A patient who is diagnosed with schizoid personality disorder is isolative, does not speak to her peers, and sits through the community meeting without speaking. Her mother de-scribes her as shy and having few friends
Which would be an appropriate nursing diagnosis for this patient?
a. Anxiety related to a new environment as evidenced by isolation and not talking with peers
b. Ineffective coping related to new environment as evidenced by isolation and minimal interaction with others
c. Impaired social interaction related to unfamiliar environment as evidenced by iso-lation and not talking with peers
d. Disturbed thought processes related to a new environment as evidenced by isola-tion and minimal interactions with others
ANS: C
This nursing diagnosis relates directly to her symptoms and their underlying pathology. Data are not present to support the other options.
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The nurse is providing discharge instructions to a client recovering from cellulitis. Which client statement indicates that this teaching has been effective?
A) "I will monitor for signs of infection such as fever, chills, malaise, and redness or tenderness at the site." B) "If the lesion looks healed, I will stop taking the antibiotics so that I will not develop resistance to antibiotics." C) "If pustules develop, I will squeeze the lesion to remove the pus." D) "Drainage from the site is an expected finding, and I should not be concerned."
To promote bowel health, the nurse recommends that the patient: (Select all that apply.)
a. exercise regularly. b. include adequate bulk in the diet. c. drink adequate water. d. defecate at approximately the same time every day. e. take a laxative to maintain a regular defe-cation pattern.
A client is experiencing chest pain that occurs in the third costochondral joint. The onset was sudden; it radiated to the shoulders; and it becomes worse when taking a deep breath or twisting the torso
The nurse suspects that this client is experiencing: 1. aortic dissection. 2. pulmonary embolus. 3. pneumothorax. 4. musculoskeletal-costochondritis.
Which nursing response would indicate an empathetic approach to a patient who is de-pressed over recent losses in her life?
a. "Losing a job isn't always a bad thing." b. "I lost my parents last year and still feel sad." c. "Please tell me more about what you are feeling." d. "Let's not focus on what's sad but rather what is good about life."