An intoxicated client is admitted through the emergency department after being found passed out on the sidewalk in a temperature of 33°C. What would be an appropriate nursing diagnosis for this client?
A) Risk for injury
B) Ineffective family coping
C) Excessive and ineffective denial of problem
D) Sleep pattern disturbance
A
You might also like to view...
During assessment, the nurse notes a third nipple about 4 inches below the patient's costal margin. What nursing action is indicated?
1. Ask the patient when this nipple appeared. 2. Document this normal variant. 3. Discuss the finding with the health care provider because these nipples are commonly malignant. 4. Look for additional nipples on the patient's back.
The Rovsing's sign and iliopsoas muscle test are useful to determine the presence of which disease process
1) Appendicitis 2) Cholecystitis 3) Duodenal ulcer 4) Hepatomegaly
A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation
As the patient's condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best? a. "I'll call your physician right away so he can discuss this with you." b. "You have the right to change your decision about treatment at any time." c. "Are you sure you want to change your decision?" d. "We must follow whatever is written in your living will."
The nurse is planning a patient's care based on Maslow's hierarchy of needs. Which human need should the nurse identify as requiring his or her immediate attention?
a. Heart rate 38 and irregular b. Plans to return to college in a year c. Needs walker adjusted to safely ambulate d. Desire to learn how to self-inject medication