A nursing diagnosis commonly applied to both paranoid schizophrenic clients and clients with
amphetamine-induced psychosis is
a. disturbed thought processes.
b. powerlessness.
c. ineffective thermoregulation.
d. deficient knowledge.
A
Paranoid delusions are commonly experienced by both types of clients; thus the nursing diagnosis of
disturbed thought processes is appropriate for both. The other options are not specifically applicable
to both.
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A 4-year-old child is admitted to the critical care unit with fever, chills, headache, vomiting, lethargy, photophobia, and nuchal rigidity. Based on these clinical manifestations, what is the anticipated diagnosis?
a. Status epilepticus c. Head trauma b. Bacterial meningitis d. Septic shock
Which client would the nurse anticipate to most likely have a higher-than-normal pulse rate?
1. An obese young adult client admitted for a fractured femur requiring traction 2. A middle-aged adult client with hypertension admitted for removal of a tumor that might be cancerous 3. A febrile elderly client with diabetes admitted for treatment of cellulitis 4. An adolescent client admitted with an anxiety disorder
The nurse is evaluating the fetal heart rate rhythm strip and determines that the amplitude varies with a rate 15 to 20 beats/min. What does this assessment finding indicate to the nurse about variability?
A) Variability is absent. B) Variability is minimal. C) Variability is normal. D) Variability is marked.
The nurse is assessing a client for complications associated with parenteral nutrition therapy. The nurse checks for crackles (rales) and weight gain to identify a(n):
1. fluid overload. 2. pneumothorax. 3. air embolism. 4. infection.