Which nursing diagnosis is appropriate for a 5-year-old child in isolation because of immunosuppression?
a. Spiritual distress
b. Social isolation
c. Diversional activity deficit
d. Sleep disturbance
C
Children in isolation need extra attention to avoid boredom. A 5-year-old child is not developmentally advanced enough to feel spiritual distress. The main social system for a 5-year-old child is the family, who should be allowed liberal visitation. Sleep disturbances may occur during hospitalization but are not specific to isolation.
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A nursing student got a thank-you card from a patient's family and had another student take a photo of the student with the family
The student asks the nursing instructor if it would be alright to post the photo on Facebook. Which response by the instructor is best? a. "Yes, as long as you ask the family if that would be OK." b. "I think that would be OK, but you should check hospital policy." c. "No, posting pictures of patients and families on social media sites is not acceptable." d. "No, that could lead to a malpractice suit by the patient or family."
The nurse notes that one of her clients is more anxious than usual. The client states, "I don't understand how I can still be alive when my heart has failed.". The nurse's most appropriate response is:
1. "It must be very confusing. Heart failure doesn't mean your heart has quit, just that it no longer is as efficient as it once was. You have internal mechanisms that work to try to keep your blood pressure from falling, but eventually these mechanisms work against the heart's ability to pump blood easily.". 2. "It seems like you are upset. Would you like for me to call the health care provider to explain this to you?" 3. "Heart failure is pretty complicated. It means the heart is failing to work.". 4. "Heart failure is a common problem in the United States. Many people have it. They all have problems such as yours.".
The nurse is obtaining a health history from a patient who has a respiratory system infection. Which finding should the nurse identify as being the most significant?
a. Flank pain b. Wheezing c. Cramping d. Anorexia
An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)
a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101 ° F. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.