The nurse has identified the following nursing diagnoses for his assigned clients. Of the follow-ing diagnoses, which one indicates the greatest potential need to plan for the client's spiritual needs?
1. Altered health maintenance
2. Ineffective individual coping
3. Impaired long-term memory
4. Decreased adaptive capacity
ANS: 2
Ineffective individual coping is a nursing diagnosis that may apply to clients in need of spiritual care. The nursing diagnosis of altered health maintenance does not indicate the greatest potential need for spiritual care. The nursing diagnosis of impaired long-term memory does not imply the need for spiritual care. The nursing diagnosis of decreased adaptive capacity does not indicate the greatest potential need for spiritual care.
You might also like to view...
A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following?
A) Continuous monitoring for portal hypertension B) Administration of immunosuppressive drugs during the first weeks after transplantation C) Real-time monitoring of vascular changes in the hepatic system D) Delivery of a continuous chemotherapeutic dose
The client is being interviewed by the nurse and is asked what symptoms they have had to bring them to the clinic. Which of the following data collected is considered subjective?
A) Blood pressure of 110/60 mm Hg B) Client states, "My chest feels tight." C) Bowel sounds present in 4 quadrants D) Client's skin is warm and dry.
Postoperatively, a client has a heart rate of 120 beats/min, with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min, and is very difficult to arouse. Which action by the nurse is most appropriate?
a. Accompany the client to the postanesthe-sia care unit (PACU). b. Keep the client in the surgical suite. c. Call a code or the Rapid Response Team. d. Transfer the client to the intensive care unit (ICU).
The nurse is assessing a terminal patient who is in the process of dying. Which cardiovascular changes will the nurse monitor for during the physical assessment early in the dying process? Select all that apply
1) Increased blood pressure 2) Decreased blood pressure 3) Increased heart rate 4) Decreased heart rate 5) Decreased peripheral pulses