The nurse is admitting a newly admitted client and notes skin vitiligo, which is highly visible even from a distance. The client asks the nurse to place a "No Visitors" sign on the door the patient's room
The client states, "I hate the way my skin looks. Some people just stare at me.". Which of the following nursing diagnoses should be incorporated into the client's plan of care? 1. Defensive coping
2. Risk for loneliness
3. Deficient knowledge
4. Disturbed body image
4
Rationale 1: Defensive coping is not the best nursing diagnosis to apply to this client. This client has a disturbed body image.
Rationale 2: The client does have a risk for loneliness but it is most likely due to the underlying disturbed body image.
Rationale 3: There is nothing to indicate that the client has a deficient knowledge. This client is suffering from a disturbed body image due to the skin's appearance.
Rationale 4: This client has a visible skin disorder and is exhibiting signs that the client has a disturbed body image.
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The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. What best identifies these sounds?
a. Crackles b. Plural friction rub c. Rhonchi d. Sonorous wheezes
The client's IV therapy for 10 hours stopped at 1030 PM. What is the correct military time that the nurse should document in the chart that the IV therapy was started?
A) 1030 PM B) 130 PM C) 1030 D) 1230
A 28-year-old woman is admitted to the ED with trauma sustained when a building collapsed. The nurse would question why which test was not ordered?
1. International normalized ratio (INR) 2. Blood alcohol 3. Pregnancy 4. Toxicology screen
The nurse is developing a safety plan for an older adult client who has just been admitted to the nursing unit. The client has limited hearing and eyesight. His medications include furosemide (Lasix) and a baby aspirin. He still lives alone in his home and is able to do small household chores but his daughter comes over every week to take him grocery shopping. Which information will have an impact on the development of the safety plan? Select all that apply.
A. The client takes furosemide. B. The client takes aspirin. C. The client has limited hearing and eyesight. D. The client lives alone. E. The client's daughter takes him grocery shopping.