A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members
The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis? a. Actual
b. Risk
c. Health promotion
d. Wellness
D
The patient's desire is to increase his specific level of wellness to a higher level of wellness. An actual diagnosis describes human responses to health conditions or life processes that exist. A risk diagnosis describes human responses to health conditions/life processes that will possibly develop. A health promotion diagnosis is a clinical judgment of a patient's motivation and desire to enhance well-being and does not require a current level of wellness.
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A 22-year-old woman has begun using axillary crutches following open reduction and internal fixation of an ankle fracture that she suffered during a basketball game
What assessment finding by the nurse should suggest that the client's crutches are fitted correctly? A) The client's elbow joint is locked when she stands upright and grasps the handgrips. B) The client's wrist is slightly hyperextended when she stands upright and grasps her crutches. C) The level of the handgrips is at the client's waist when she stands upright with her crutches. D) The axillary bar is 3 to 4 in. below the client's axilla when she stands upright.
A patient with Raynaud's disease presents with pallor of the fingers. The patient states that the hands turn white, then blue, then red. How should the nurse explain these symptoms to the patient?
1. "Bleeding is occurring in the interior portion of your hands.". 2. "You have inflammation of the small vessels of your hands and feet that will eventually form small clots.". 3. "These symptoms are caused by spasm of the small arteries and arterioles in your hands.". 4. "Your symptoms are associated with atherosclerosis caused by too many circulating lipids.".
A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n)
a. elevated hematocrit. b. decreased serum sodium. c. low urine specific gravity. d. increased serum chloride.
The nurse cares for a patient diagnosed with schizophrenia. For which reason should the nurse use an eclectic approach with this patient?
1. There is a lack of care philosophies to direct nursing practice. 2. It is difficult to determine a final plan of care for a patient with a psychotic disorder. 3. There is limited scientific evidence about treatment for schizophrenia, so a variety of medications and interventions must be tried over time. 4. Strategies from one or a combination of psychiatric theories and therapies are used to determine interventions and evaluation criteria for working with each patient.