An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies?
a. Hopelessness
b. Powerlessness
c. Chronic low self-esteem
d. Disturbed thought processes
ANS: B
The patient describes feelings of lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's thought processes are not altered at this point.
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The nurse is evaluating the effectiveness of teaching provided to a client with erectile dysfunction. Which comment made by the client should be addressed by the nurse?
1. "I do not want to upset my wife so I will share my concerns with you." 2. "I know there are surgical options if I cannot tolerate the pills." 3. "I am not embarrassed to tell you I am unable to have an erection." 4. "I know I need to take the sildenafil (Viagra) about an hour before having sex."
A client has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.)
a. "How much water do you drink every day?" b. "Do you take estrogen replacement?" c. "Does anyone in your family have a his-tory of cystitis?" d. "Do you have any condition that affects your immune system?" e. "Are you on steroids or other immune suppressant drugs?" f. "Do you drink grapefruit juice every day?"
A 10-year-old girl needs to have another intravenous (IV) line started. She keeps telling the nurse, "Wait a minute," and, "I'm not ready." How should the nurse interpret this behavior?
a. IV insertions are viewed as punishment. b. This is expected behavior for a school-age child. c. Protesting like this is usually not seen past the preschool years. d. The child has successfully manipulated the nurse in the past.
During the assessment interview, the client is quiet and answers questions only minimally. What action should the nurse take in regard to this apparent unwillingness to share information?
1. Document that the client is not cooperative. 2. Consider any cultural implications of these actions. 3. Assume that the client has something to hide. 4. Ask another nurse to sit in on the next interview attempt.