A patient comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection?
A) Stress may adversely affect normal defense mechanisms.
B) White blood cells provide resistance to certain pathogens.
C) Intact skin and mucous membranes protect against microbial invasion.
D) Age, race, sex, and hereditary factors influence susceptibility to infection.
C
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Due to increased left atrial pressure, a patient with mitral stenosis often suffers from:
A. Pulmonary congestion B. Hepatomegaly C. Jugular venous distension D. Ventricular tachycardia
Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L?
a. Measuring urine output b. Measuring abdominal girth c. Monitoring fluid intake d. Comparing radial versus apical pulses
What is the rationale for establishing a contract with a patient with an eating disorder at the beginning of treatment?
a. The patient and nurse form a coalition that is difficult for the family to disrupt. b. A team approach to planning therapy ensures that physical and emotional needs will be met. c. Patient involvement in decision making increases the sense of control and promotes cooperation. d. Permission for refeeding is essential because this measure has the potential for negative effects.
A manic client in the acute phase is verbally and physically aggressive to himself. The nursing diagnosis Defensive coping related to biochemical changes as evidenced by aggressive verbal and physical behaviors has been identified. A desirable short-term goal would be that the client will
A. Making no attempts at self harm within 12 hrs of admission. B. sleep soundly for 12 of the next 24 hours. C. willingly take prescribed medication as offered by staff within 24 hours of admission. D. develop psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission.