Which of the following describes the process of identifying a nursing diagnosis?
a. Selecting a nursing diagnosis from a list approved by the North American Nursing Diagnosis Association (NANDA)
b. Identifying the patient's strengths and weaknesses
c. Setting goals for nursing care
d. Reviewing medical-surgical nursing texts for patterns of disease processes
B
The process of identifying a nursing diagnosis starts with evaluating a patient's strengths and weaknesses. The NANDA-approved list (response A) provides diagnostic labels for the patient's strengths and weaknesses. Response C, setting goals, follows identification of the nursing diagnosis. Response D, reviewing medical-surgical texts, assists the nurse in understanding responses to disease and assists in designing care plans but does not identify nursing diagnoses.
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A pediatrician orders Russell traction for a 12-year-old patient with Legg-Calvé-Perthes disease. Which interventions are appropriate for the nurse to include in the care plan for this patient? (Select all that apply.)
A. Bony areas are massaged frequently. B. Child is lying in a supine position. C. Hip is flexed and abducted. D. Skin is inspected every 12 hours. E. The child uses a trapeze to move.
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a. "Aging alters our sleep patterns, so what you describe is really quite common." b. "Circadian sleep rhythms are controlled by the hypothalamus, which is affected by age." c. "Sleep patterns are affected by so many things; have you been under a lot of stress lately?" d. "Can you be more specific about what you think is wrong with your sleep pattern?"
A client is prescribed theophylline to relax the smooth muscles of the bronchi. The nurse monitors the client's theophylline serum levels to maintain which therapeutic range?
a. 1 to 10 mcg/mL b. 10 to 20 mcg/mL c. 20 to 30 mcg/mL d. 30 to 40 mcg/mL