A client admitted for treatment of trauma sustained in a fall while intoxicated believes bugs are
crawling on the bed. The client is anxious, agitated, and diaphoretic. A nursing diagnosis of high
priority that should be developed is
a. ineffective health maintenance.
b. ineffective coping.
c. ineffective denial.
d. risk for injury.
D
The client's clouded sensorium, sensory perceptual distortions, and poor judgment put him at risk
for injury. The scenario does not provide data to support the other diagnoses.
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A patient tells his family, "I don't know why I was placed on this earth just to suffer from cancer all my life. I just want to die." The nurse realizes the patient
a. has lost control of the situation. b. is expressing spiritual despair. c. is becoming anxious with the situation. d. will become withdrawn from his or her care.
When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery,
the nurse determines that additional teaching is needed when the patient says which of the following? a. "They will circulate my blood with a machine during the surgery." b. "I will have small incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take an aspirin every day after the surgery to keep the graft open."
The nurse is assessing for fatigue in a patient diagnosed with multiple sclerosis. Which self -reporting tool is best for the nurse to utilize?
a. Multidimensional Assessment of Fatigue (MAF) b. Fatigue Severity Scale (FSS) c. Brief Fatigue Inventory (BFI) d. Multidimensional Fatigue Inventory (MFI)
The nurse is reinforcing patient teaching on the best way to prevent transmission of infectious diarrhea. Which of the following statements by the patient would indicate correct understanding of the teaching?
a. Keep the perineal area clean and dry. b. Wash hands frequently and after toileting. c. Wear a mask and gown. d. Avoid sharing eating utensils.