The nurse considers a nursing diagnosis of ineffective health maintenance related to low motivation for a patient with diabetes. Which finding would the nurse most likely use to support this nursing diagnosis?
a. The patient does not perform capillary blood glucose tests as directed.
b. The patient occasionally forgets to take the daily prescribed medication.
c. The patient states that dietary changes have not made any difference at all.
d. The patient cannot identify signs or symptoms of high and low blood glucose.
ANS: C
The patient's motivation to follow a diabetic diet will be decreased if the patient feels that dietary changes do not affect symptoms. The other responses do not indicate that the ineffective health maintenance is caused by lack of motivation.
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During discussion with the patient and the patient's husband, you discover that the patient has a living will. How does the presence of a living will influence the patient's care?
A) The patient is legally unable to refuse basic life support. B) The physician can override the patient's desires for treatment if desires are not evidence-based. C) The patient may nullify the living will during her hospitalization if she chooses to do so. D) Power-of-attorney may change while the patient is hospitalized.
A nurse is teaching a client how to use nitroglycerin tablets to be kept at the client's bedside for PRN use. The nurse should instruct the client that to be effective, these tablets are to be:
a. chewed and then swallowed without water b. dissolved on top of the tongue c. dissolved under the tongue d. swallowed with a small amount of water
A 19-year-old college football player has been hospitalized with a knee injury. When sending his diet orders to the hospital kitchen, the nurse knows what to include?
A) Extra servings of protein B) Extra servings of carbohydrates C) Extra servings of grains D) Extra servings of fats
When asked to define the purpose of diagnostic reasoning, the best nursing response is:
1. "Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis." 2. "The diagnostic reasoning process flows from the assessment process and includes decision-making steps." 3. "Diagnostic reasoning includes data clustering, identifying client needs and for-mulating the diagnosis or problem." 4. "Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis."