An appropriate nursing diagnosis for a client who frequently expresses guilt or shame, states that he is unable to deal with situations, and is hesitant to try new things would be:

1. Chronic low self-esteem
2. Powerlessness
3. Hopelessness
4. Ineffective coping


ANS: 1
The behaviors mentioned in the situation are congruent with criteria for the diagnosis of chronic low self-esteem. 2. The client's symptoms go beyond powerlessness. 3. Hopelessness does not involve feelings of guilt and shame. 4. The data are not consistent with a diagnosis of ineffective coping.

Nursing

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A woman with polyhydramnios was admitted to a labor-delivery-recovery-postpartum (LDRP) suite. Her membranes rupture, the fluid is clear and odorless, but the fetal heart monitor indicates bradycardia and variable decelerations

What action should be taken next? a. Perform a vaginal examination. b. Perform Leopold's maneuvers. c. Apply warm saline soaks to the vagina. d. Place the woman in high-Fowler's position.

Nursing

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as

possibly being affected? A) Liver B) Ileum C) Stomach D) Large intestine

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A 78-year-old patient's respiratory vital capacity measurement is decreased. How would the nurse evaluate this information?

1. The patient will likely also have cardiac insufficiency. 2. This finding can be normal in older patients. 3. This finding indicates neurological deterioration. 4. This patient has had undiagnosed chronic respiratory disease.

Nursing

Parents of an infant with slow weight gain ask the nurse if they can feed their baby a highly concentrated formula. An appropriate response given by the nurse would be

1. "A higher-concentrated formulacould lead to dehydration because of high sodium content;let's discuss other strategies." 2. "An undiluted formula concentratecould be given to help the child gain weight;let's look at brands." 3. "Evaporated milk could be given tothe infant instead of the current formula you're using." 4. "A higher-concentrated formulacould be given for daytime feedings; let's work on a schedule."

Nursing