A woman presents at the emergency department with sharp, colicky pain in her right abdomen that radiates to her right shoulder
She tells the nurse that she has been spotting lightly for the past few days. Based on the assessment data what is a major nursing diagnosis the nurse would include in this patient's care plan?
A) Deficient knowledge related to the treatment and effect on future pregnancies
B) Unplanned anticipation related to the pregnancy
C) Acute pain related to the progression of the pregnancy
D) Anticipatory effect on future pregnancies
Ans: A
Feedback: Based on the assessment data, major nursing diagnoses may include the following: Acute pain related to the progression of the tubal pregnancy; Anticipatory grieving related to the loss of pregnancy and effect on future pregnancies; and Deficient knowledge related to the treatment and effect on future pregnancies. Options B, C, and D are not NANDA-approved diagnosis and are therefore incorrect.
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The interdisciplinary treatment team is discussing appropriate strategies for a homebound client who has a history of medication nonadherence
Which of the following rationales should the nurse case manager use when a treatment team member suggests that the nurse case manager make daily home visits to administer medications? 1. "My job description does not include medication administration to clients in the home." 2. "My role as case manager is to remain objective and look at the whole picture. If I deliver direct care, I may lose this perspective." 3. "My time is more importantly spent supervising others to provide this type of direct care." 4. "My daily schedule is too full to commit this amount of time to administering medications."
A preadolescent client is recovering from spinal fusion surgery for scoliosis. Which interventions would be appropriate related to movement restrictions and pain?
Select all that apply. A) Reposition every 2 hours. B) Monitor intake and output. C) Encourage and assist with ROM exercises every 4 hours while awake. D) Administer pain medication around the clock. E) Encourage incentive spirometer use every 4 hours while awake.
The nurse is performing an assessment of a 13-year-old boy with diabetes mellitus. Which of the following assessments would best indicate the presence of type 1 diabetes?
A) The parents report that their child had "a cold or flu" recently. B) Checking the vital signs shows an elevated blood pressure. C) The parents report that their son "can't drink enough water and is tired a lot." D) Auscultation reveals Kussmaul breathing.
The staff development trainer is preparing information for a seminar on the Quality and Safety Education for Nurses (QSEN) initiative as part of the National Safety Week celebration
Which attributes should the trainer emphasize as being an integral part of this initiative? (Select all that apply.) 1. Skills 2. Caring 3. Attitudes 4. Education 5. Knowledge