Your client sustained a right femoral neck fracture and underwent pinning of the right hip. Twenty-four hours after surgery, you charted the following: Right hip dressing clean, dry, and intact
Dressing changed qd by RN using sterile technique. Your charting documents interventions appropriate for which of the following nursing diagnoses?
1. Impaired tissue integrity
2. Body image disturbance
3. Hopelessness
4. Impaired skin integrity
ANS: 4
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A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not
Which nursing diagnosis, which was recently removed from the NANDA-I list, still accurately reflects this client's problem? 1. Disturbed thought processes 2. Disturbed sensory perception 3. Anxiety 4. Chronic confusion
The nurse is assessing a patient new to the clinic. The patient says she is allergic to penicillin. What would be the nurse's appropriate next action?
A) Ascertain the exact nature of the patient's response to the drug. B) Document the patient is allergic to penicillin. C) Mark the patient's chart in red that she has a penicillin allergy. D) Continue to assess the patient for other allergies.
A client who is obese tells the nurse that malnutrition is not a problem. What should the nurse include when responding to this client?
a. This is correct information. b. Nutrient deficiency is the best indicator of malnutrition. c. A lot of research about malnutrition is being conducted. d. Malnutrition can be an excess or deficiency of nutrients.
A client who had a hysterectomy a few days ago begins to exhibit symptoms of elevated temperature 2 or 3 days following surgery, severe pain, redness or swelling around the incision, and an elevated white blood count
What potential complication following surgery is most likely to be the cause of these symptoms? A) Postoperative infection B) Pulmonary embolism C) Hypovolemic shock D) Atelectasis