A female patient tells the nurse that she has been having nightmares and acute anxiety around men since being sexually assaulted 3 months ago. The most appropriate nursing diagnosis for the patient is
a. anxiety related to effects of being raped.
b. sleep deprivation related to frightening dreams.
c. rape-trauma syndrome related to rape experience.
d. ineffective coping related to inability to resolve incident.
ANS: C
The patient's symptoms are most consistent with the nursing diagnosis of rape-trauma syndrome. The nursing diagnoses of sleep deprivation, ineffective coping, and anxiety address some aspects of the patient's symptoms but do not address the problem as completely as the rape-trauma syndrome diagnosis.
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The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP?
a. "The action of the machine will improve blood supply to the damaged heart." b. "The machine will beat for the damaged heart with every beat until it heals." c. "The machine will help cleanse the blood of impurities that might damage the heart." d. "The machine will remain in place until the patient is ready for a heart transplant."
You are developing a care plan for a patient with Cushing's syndrome. What nursing diagnosis would have the highest priority in this care plan?
A) Risk for injury related to weakness B) Disturbed body image related to changes in physical appearance C) Risk for loneliness related to disturbed body image D) Fatigue related to sleep disturbances
Functions of the middle ear include:
a. creation of cerumen c. pressure equalization b. equilibrium d. closure of the oval window
Which symptom indicates a need for immediate intervention in a client with a rolling hernia?
a. Reflux b. Crackles in the lungs c. Distended and firm abdomen d. Two episodes of diarrhea