After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis?
A) Impaired urinary elimination
B) Readiness for enhanced sleep
C) Risk for infection
D) Possible impaired adjustment
Ans: A
Impaired urinary elimination is an actual nursing diagnosis because it describes a human response to a health problem that is being manifested. Readiness for enhanced sleep is a wellness diagnosis. Risk for infection is a risk diagnosis, and possible impaired adjustment is a possible nursing diagnosis.
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Suzanne's evaluation is due in 2 weeks. Yesterday, she came in early to help with a staffing crisis and actually saved a choking family member by performing the Heimlich maneuver
Her evaluation is certain to be full of high praise for her skills and teamwork. a. This is a fair evaluation; after all, she has been great the last 2 weeks b. This is a fair evaluation; the manager really cannot remember any problems with Suzanne this last year c. This is a situation in which a halo error is influencing the entire evaluation d. This is a situation in which a leniency error is influencing the entire evaluation
The nurse is assessing a woman in the immediate postpartum period. The patient's respiratory rate is 22 breaths/minute. The most important aspects of nursing care would be to do which of the following? (Select all that apply.)
A. Assess and provide pain management. B. Assess the patient's blood pressure and pulse. C. Increase the patient's fluid intake. D. Notify the provider for continued tachypnea. E. Provide ongoing physical assessment.
The nurse plans to encourage an anxious client to talk about his feelings and concerns. The rationale
for this intervention is that a. offering hope allays the client's anxiety. b. concerns stated aloud become less overwhelming and can serve as the basis for problem solving. c. anxiety can be reduced by focusing on and validating what is occurring in the environment. d. encouraging clients to explore alternatives increases the sense of control and lessens anxiety.
Which statement is accurate regarding the resistance of blood flow through vessels?
a. The most important determinant of resistance is vessel diameter. b. Resistance to blood flow is affected the most by vessel length. c. Blood viscosity is the greatest determinant of resistance to blood flow. d. Vessel diameter, vessel length, and blood viscosity are all equal determinants.