Which nursing diagnosis would the nurse include in the plan of care for a patient with a catheter embolism?
1. Ineffective Coping
2. Fluid Volume Deficit
3. Impaired Skin Integrity
4. Alteration in Comfort
4
Rationale 1: The manner in which a patient copes does not impact this life-threatening emergency.
Rationale 2: A catheter embolism does not reflect signs of fluid loss but rather of decreased vascular perfusion.
Rationale 3: The catheter has broken inside the patient's vasculature, and skin integrity will not be altered.
Rationale 4: The patient often experiences chest pain with a catheter embolism.
You might also like to view...
For a functionally illiterate client, the nurse particularly focuses on:
1. Using intricate analogies and examples 2. Avoiding lengthy return demonstrations 3. Incorporating familiar nonmedical terminology 4. Providing longer learning sessions with the client
The nurse is caring for a client who states, "No one can understand God." The nurse would document the client's spiritual belief as:
A) atheist. B) agnostic. C) theist. D) holistic.
An awake, alert 4-year-old child has just arrived at the emergency department after an ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which manner?
a. Giving half of the solution and then repeating the other half in 1 hour b. Mixing with a flavorful beverage in an opaque container with a straw c. Serving it in a clear plastic cup so the child can see how much has been drunk d. Administering it through a nasogastric tube because the child will not drink it because of the taste
A new nurse from another country is caring for a client on the unit. The new nurse asks the preceptor to explain the difference between dementia and delirium so that appropriate care can be planned for the client
The best response by the preceptor is which of the following? 1. The cause of delirium is unknown. 2. Delirium develops over several weeks. 3. Delirium is often confused with depression in clients over the age of 60. 4. Delirium is a common occurrence in hospitalized clients over the age of 60.