Your client is a 35-year-old woman with multiple sclerosis. She is unable to voluntarily move any part of her body except for her thumb. She is fed by a G-tube. Her nursing diagnosis would include:
1. Risk for activity intolerance.
2. Impaired physical tolerance.
3. Activity intolerance.
4. Impaired physical mobility.
ANS: 4
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A 16-year-old client has a long leg cast secondary to a fractured tibia. The child will require a wheelchair for mobility. To effectively facilitate the adolescent's return to school, the school nurse should:
1. Meet with all of the other students prior to the student's return to school to emphasize the special needs of the injured teen. 2. Meet with teachers and administrators at the school to discuss modifications in the student's school routine. 3. Develop an individualized health plan (IHP) focusing on long-term needs of the adolescent. 4. Meet with parents of the injured student to encourage homebound schooling until a short leg cast is applied.
A nurse is conducting an in-service presentation for a group of nurses about UTIs and hospitalized clients. When discussing preventive measures, the nurse would identify which of the following as the primary nursing intervention for prevention?
A) Proper perineal hygiene B) Use of urinary acidifiers C) Hand hygiene D) Routine urinalysis
What should a nurse ask a patient related to past history of deep-vein thrombosis (DVT) and other vascular problems?
a. An aneurysm b. Rheumatoid arthritis c. A peptic ulcer d. Recurring chest pain
The nurse is assigned to a 52-year-old male patient. He is talkative and usually friendly when the nurse enters his room. Today, however, he is standing at the mirror and says: I lost my job because the company downsized, there isn't anything I can do
As his caregiver, the nurse recognizes this expression of concern is related to which of the following? A) He assumes the termination is his fault. B) Dissatisfaction with changes in his appearance and energy levels. C) His career goals and retirement plans are compromised. D) He is in an androgenic crisis.