The nurse is contributing to a plan of care for a patient who has had a 5 pound weight gain in 2 days, pitting edema of the ankles, lung crackles, and distended neck veins. Which nursing diagnosis would be given priority in the plan of care?
a. Noncompliance
b. Urinary Retention
c. Excess Fluid Volume
d. Ineffective Health Maintenance
ANS: C
The manifestations observed are indicative of excess fluid volume.
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The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
a. Supine with the head of the bed elevated 30 degrees b. In a high-Fowler's position with the left arm extended c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table
The nurse is observing a playgroup of children of all ages. The preschoolers in the group would most likely be doing which activity?
A) Pretending to be mommies and daddies in the playhouse B) Playing with the plastic vacuum cleaner, pushing it around the room C) Painting pictures in the art corner of the room D) Watching a movie with other children of their age
What is the name of the vascular malignancy that can occur anywhere in the body, but whose first lesions often appear on the face or oral cavity in clients with acquired immunodeficiency syndrome (AIDS)?
a. Kaposi's sarcoma c. oral hairy leukoplakia b. oral candidiasis d. non-Hodgkin's lym-phoma
A nurse is planning a refugee outreach clinic at the neighborhood health center. To provide culturally competent care, the nurse should consider that (select all that apply):
a. Their own background, beliefs, and knowledge may be significantly different from those of the people receiving care. b. Language barriers may interfere with efforts to provide assistance. c. Certain risk factors may be present for a given population. d. Certain groups may use non-traditional healing practices.