Your 88-year-old patient is hospitalized for a retinal detachment. He is on bed rest, and both eyes are covered with patches. Which nursing diagnosis takes priority at this time?
a. Self-esteem disturbance related to de-creased independence
b. High risk for altered thought processes related to visual impairment
c. High risk for injury related to altered sen-sory perception
d. Impaired social interaction related to vis-ual deficit
C
If the eyes are patched, safety precautions, such as keeping call lights, side rails, and necessary items within reach, must be instituted. Finally, assistance must be provided with activities of daily living (ADLs) and walking as needed to promote comfort and safety. The other diagnoses may be appropriate for selected patients.
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When a client does not respond to verbal stimuli, to determine level of consciousness the nurse should
a. apply pressure across the client's nail bed. b. ask the client to squeeze the nurse's fingers. c. check deep tendon reflexes. d. lightly pinch the skin of the hand.
An infant is tachypneic, retracting, and tachycardic with a temp of 39.0 C and a pulse oximetry of 92 percent. You place the infant on 1L nasal cannula oxygen and raise the head of the bed
What intervention would the nurse expect the physician to order next? 1. MRI 2. CT 3. Bronchoscopy 4. Chest x-ray
The family of a hospice client is holding a vigil at the client's bedside. During a visit, a hospice nurse participates in this vigil and encourages each of the family members to say their good-byes. The nurse is demonstrating which of the following?
A) Palliative care B) Guided letting go C) Connecting D) Responsive use of self
The nurse is caring for a patient recovering from surgery. Which intervention will provide the most pain relief for the patient?
A. Wait until the patient can describe the pain specifically. B. Offer pain relief before the patient complains of pain. C. Allow the patient to "sleep off" the anesthesia, then offer pain medication. D. Assess the pain level every 4 hours around the clock.