The nurse assesses a patient with a temporal bone fracture and notices drainage from the right nostril. Based on this assessment, which nursing diagnosis should the nurse document as priority?
1. Risk for Pain
2. Risk for Impaired Sensory Input
3. Ineffective Airway Clearance
4. Potential for Infection
4
Rationale 1: The patient may have pain, but this is not the priority.
Rationale 2: The patient is likely to have impairment of sensory input, but this is not the priority nursing diagnosis.
Rationale 3: The patient's airway may be compromised by the fluid, but there is no indication that the impairment is serious.
Rationale 4: Potential for Infection is the nursing diagnosis that should be documented in the chart, as the drainage may indicate a cerebrospinal fluid leak.
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A) Narcotic-induced pain B) Acute pain C) Phantom limb pain D) Chronic pain
Which of the following clients is probably going to start exercising in the near future?
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The nurse is asked by a client which drug regimens have been shown to be the most successful for the initial therapy of HIV infection. The nurse responds:
Standard Text: Select all that apply. 1. "An NNRTI-based regimen." 2. "PI-based regimens." 3. "An integrase inhibitor-based regimen." 4. "NRTIs/NtRTIs-based regimens." 5. "Entry inhibitor-based regimens."
The nurse is teaching a patient with sickle cell anemia how to prevent crises. Which foods should the nurse teach the patient to avoid?
a. Alcoholic beverages b. Citrus fruits c. Chocolates and colas d. Whole grain products