The nurse calculates an elderly client's body mass index as 19. Which of the following NANDA diagnoses would be appropriate?
1. Knowledge deficit
2. Fluid volume deficit
3. Altered nutrition: less than body requirements
4. Impaired metabolism
3
Rationale: A client with a BMI of < 20 is considered underweight, so the client is has a nutrient deficit. There is nothing to conclude that the client has a knowledge or fluid volume deficit, merely because the client is underweight. Impaired metabolism is not an accepted NANDA diagnosis.
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A postpartum client is experiencing pain from an episiotomy. Which actions will the nurse suggest to the client to decrease discomfort? Select all that apply
A) Washing the area with soap and water every day B) Tightening the buttocks before sitting C) Changing peripads daily D) Performing leg scissor kicks several times a day E) Increasing the intake of meat, cheese, fish, eggs, and nuts
Which of the following information is true regarding the assessment of the thyroid or thyroid function in an infant or child?
1. To accurately assess thyroid function, the nurse should assess the child's growth and development in comparison to others in the child's age group. 2. The thyroid gland is easily palpable in an infant. 3. Assess the child for abnormal hair growth because this may indicate thyroid dysfunction. 4. Assess the child for melasma because this will indicate thyroid dysfunction.
After analyzing assessment data, the home health care nurse determines that a change is necessary in the medical care of a patient. The nurse makes the change without consulting the physician
Under which circumstance is this a legal action by this nurse? 1. If the nurse is experienced and sure the change will not harm the patient 2. If there is a signed, standing order for the change 3. If the nurse is certain the physician will agree with the change 4. If the patient's family agrees that the action is necessary
To include a cultural focus in client care planning, which of the following beliefs about faith will the nurse incorporate? Faith is a:
1. Belief of body and mind 2. Manner of expressing spirituality 3. Use of spiritual resources without empiric proof 4. Search for the sacred, transcendent, or universal