A patient's employment is terminated and major depression results. The patient says to the nurse, "I'm not worth the time you spend with me. I'm the most useless person in the world." Which nursing diagnosis applies?
a. Powerlessness
b. Defensive coping
c. Situational low self-esteem
d. Disturbed personal identity
ANS: C
The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of Situational low self-esteem. Insufficient information exists to lead to other diagnoses.
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a. Repeat subsequent puffs, if ordered, after 5 minutes. b. Inhale slowly while pressing down to release the medication. c. Inhale quickly while pressing down to release the medication. d. Administer the inhaler while holding it 3 to 4 inches away from the mouth.
The nurse instructs a group of older adults on how to maintain intact skin. What would be included in the teaching plan? (Select all that apply.)
a. Altering their body position every 30 minutes while sitting in the chair b. Changing incontinent products when they become soiled c. Using a pressure-relieving device like the "donut" to sit on d. Routinely checking their feet for redness and indentations e. Patting the skin dry after a shower or bath
A strategy to promote achievement of long-term goals is
a. striving to complete the entire goal at one time. b. eliminating any undesirable elements of the goal. c. jumping right in at any point that is appealing. d. creating a series of related short-term goals.
Which is used to remove grease spills and splashes?
a. Powdered cleanser and hot water b. A wet sponge c. A liquid surface cleaner d. Scouring powder