A client admitted to a Veterans Administration (VA) hospital with a diagnosis of major depressive disorder tells the nurse, "I failed my battalion by giving the wrong order. Fortunately, no one was injured."
Which nursing diagnosis should the nurse assign to this client?
A. Chronic low self-esteem
B. Risk for self-directed violence
C. Powerlessness
D. Situational low self-esteem
ANS: D
Emotional responses are largely dependent on cognitive appraisals of the significance of environmental cues. The nursing diagnosis of situational low self-esteem is used for individuals who have a negative perception of self-worth in response to a current situation. This client's cognitive appraisal of the situation has led to the diagnosis of major depressive disorder and low self-esteem.
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The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine into the toilet at a time
The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority nursing diagnosis for this patient? a. Alteration in comfort r/t continual urge to urinate b. Overflow urinary incontinence r/t over-distention of the bladder c. Urinary retention r/t obstruction of urinary bladder outlet d. Toileting self-care deficit r/t inability to pass urine into the toilet
In light-skinned individuals, a scrotal mass with a bluish discoloration may be caused by
a. accumulation of fluid in the testis. b. blockage of the efferent ductules of the rete testis. c. dilated veins in the pampiniform plexus of the spermatic cord. d. oily, fatty matter secreted by the sebaceous glands.
Who was an author of a theory that focused on self-care?
a. Nightingale c. Abdellah b. Levine d. Orem
The nurse assesses the client's incontinent urinary diversion and observes reddened peristomal skin. Which is the best nursing intervention to promote skin integrity?
1. Apply an antiseptic ointment. 2. Keep the peristomal area dry. 3. Change the pouching equipment. 4. Fit stoma with a tight skin barrier.