The nurse is planning care for a patient undergoing diagnostic evaluation for presence of an intracranial bleed. Which nursing diagnosis (NDX) would the nurse set as the first priority?
1. Impaired Verbal Communication
2. Potential for Aspiration
3. Risk for Altered Cerebral Tissue Perfusion
4. Altered Coping
3
Rationale 1: The patient may have impairment of verbal communication, so this is an appropriate NDX but is not the priority.
Rationale 2: The patient may be at risk for aspiration, but this is not the priority NDX.
Rationale 3: The highest risk and most encompassing NDX are related to the possibility of stroke. This is the nurse's highest priority NDX.
Rationale 4: The patient may have serious coping needs, but this is not the priority NDX.
You might also like to view...
The nurse receives a laboratory report that states her patient's digoxin level is 1.2 ng/mL; therapeutic range for this drug is 0.5 to 2 ng/mL. Which action should the nurse take?
1) Notify the prescriber to reduce the dose. 2) Withhold the next dose of digoxin. 3) Administer the next dose as prescribed. 4) Notify the prescribing healthcare provider to increase the dose.
The nurse is performing a nutritional assessment for an older adult who takes no medications. Which of the following laboratory values is of most concern to the nurse?
1. Albumin 4.2 gm/L 2. Prealbumin 322 mg/L 3. Transferrin 400 mg/dL 4. Cholesterol 114 mg/dL
The primary objective of hospice care is to:
1. Increase the quality of remaining life 2. Reduce the care of terminally ill 3. Keep clients at home 4. Provide care for terminally ill clients expected to live longer than 6 months
A group of nurses are working on a committee to develop a program that promotes the adoption of evidence-based nursing at the facility. Which of the following would the committee need to address? Select all that apply
A) Improved access to resources for the staff B) Use of valued nurses for staff to seek out with questions C) Emphasis on the value of information seeking D) Greater focus on high-priority organizational goals E) Enhanced familiarity of staff to evidence-based practice