A nurse is assessing a 10-year old child with severe sickle cell disease. The mother states the child used to love school but now "won't go and won't play with any friends
" The nurse notes the child is very thin with an oddly-shaped head and has significant ptosis. Which nursing diagnosis best fits this client? a. Altered family coping related to effects of disease on family
b. Anxiety related to fear of the unknown and social stressors
c. Readiness for Enhance Self Care related to disease and treatment
d. Social Isolation related to body image changes
D
The child is isolating him/herself probably because of the unanticipated body image changes that have accompanied frequent bouts of SCD crisis. Anxiety might be the real problem, but without any further information Social Isolation is more appropriate.
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a. Green and loose b. Dark green and sticky c. Pale yellow and frequent d. Light brown and pasty
A client admitted to the hospital after being involved in a motor vehicle collision develops hypotension and severe jugular distension with a tracheal deviation. What does the nurse suspect has occurred?
1. Hemorrhage 2. Tension pneumothorax 3. Compensatory shock 4. Hypovolemic shock
Negligence may be accidental or deliberate.
Answer the following statement true (T) or false (F)
The nurse is reinforcing teaching provided to a patient to learn how to get out of bed independently at home after surgery. What should the nurse emphasize in this teaching? (Select all that apply.)
a. Hold breath while sitting. b. Place the hands flat against the bed. c. Turn onto the side without a pillow between the knees. d. Sit for a few minutes to avoid dizziness and falling. e. Push up while swinging the legs into a sitting position.