A patient who lost his job last month has now been told that his wife wants a divorce. He says, "I know I don't have much to offer a woman. She wants more than what I am, and now I'm not even bringing home any money
" Which nursing diagnosis is most appropriate?
a. Chronic Low Self-Esteem
b. Situational Low Self-Esteem
c. Disturbed Personal Identity
d. Disturbed Body Image
B
Situational Low Self-Esteem occurs when a person exhibits self-disapproval and negative self-evaluations as a specific reaction to loss or change (in this case, of a job and a marriage). There are no data to indicate long-standing (chronic) Low Self-Esteem. This client has no defining characteristics for Disturbed Personal Identity, which is an inability to determine boundaries between self and others, nor of Disturbed Body Image. He does mention his appearance but does not focus on it in particular; it is only part of his overall dissatisfaction with himself.
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A nurse who works with families uses Duvall's family developmental theory as the core of nursing practice. What action by this nurse takes priority?
A. Assessing the developmental stage of the family B. Determining how the family interacts with society C. Observing what roles each family member assumes D. Tailoring teaching to the specific needs of the family
All of the following interventions are ordered stat. for a patient stung by a bee who is experiencing severe respiratory distress and faintness. Which priority intervention will the nurse administer first?
A) Epinephrine (Adrenalin) B) Normal saline infusion C) Dexamethasone (Decadron) D) Diphenhydramine (Benadryl)
The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should Answer:
a. "Pancreatitis is extremely rare and no one knows why it causes pain." b. "Pancreatitis is caused by diabetes; you should be checked." c. "Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain." d. "The pain is localized to the pancreas. Fortunately, it will not affect anything else."
The nurse is caring for a client with severe cardiovascular disease and schizophrenia. Which antipsychotic medication would be the safest treatment for this client?
1. Ziprasidone (Geodon) 2. Paliperidone (Invega) 3. Risperidone (Risperdal) 4. Aripiprazole (Abilify)