The nurse is developing a care plan for a client who has had a stroke and is unable to assist with care at this time. Which problem would the nurse deem a top priority?
A) Risk for development of a pressure ulcer
B) Risk for Injury
C) Ineffective Breathing Pattern
D) Social Isolation
C
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Nurses must rank any problem that poses a threat to physiologic functioning first. For example, nursing diagnoses such as Ineffective Breathing Pattern and Deficient Fluid Volume demand the nurse's attention more than other diagnoses because these situations may be life threatening. The other diagnoses are second level and higher. This relates to Maslow's hierarchy.
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A 38-year-old male patient stopped smoking 6 months ago
He tells the nurse that he still feels strong cigarette cravings and wonders if he is ever going to feel "normal" again. Which statement by the nurse is correct? a. "It's possible that these cravings will never stop." b. "These cravings may persist for several months." c. "The cravings tell us that you are still using nicotine." d. "The cravings show that you are about to experience nicotine withdrawal."
Which discharge instruction is appropriate for an adolescent client who is a paraplegic due to a motor vehicle accident, in order to prevent decubitus ulcer formation on the buttock?
1. Contract the muscles 5 times every 2 hours. 2. Increase fat in the diet to provide a protective coating over the boney bony prominences. 3. Do wheelchair push-ups every 15 to 30 minutes. 4. Avoid use of sheepskin, as it prevents air from reaching the area.
When the kidneys are diseased, the body may not be able to maintain a balance between intake and output, and it is sometimes necessary to keep track of the intake and output of
A. foods. B. fluids. C. electrolytes. D. medications.
Which agents are preferred for the initial treatment of hypertension?
a. ACE inhibitors and angiotensin receptor antagonists b. Calcium ion agonists and central acting alpha agonists c. Thiazide diuretics and beta-adrenergic blockers d. Direct vasodilators and peripherally acting adrenergic antagonists