The nurse planning care for a client with discoid lupus erythematosus sets which goal in collaboration with the client?
1. Will work through the stages of death and dying.
2. Will gain weight to within 10 pounds of normal for height.
3. Will comply 100% of the time with sun-protection plan.
4. Will report pain no higher than 4 on a scale of 1-10.
3
Rationale: Discoid lupus erythematosus is an autoimmune disorder of the skin, so the client must protect against the sun to avoid skin cancers and other complications. It is not fatal, is not related to weight, and is rarely painful unless complications arise.
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A nurse in a level III trauma center is preparing her patient for transport to a level I trauma center. How should the nurse describe a level I trauma center to the patient and family?
A) Basic trauma services are available, but the center is not involved in community education programs. B) Basic trauma services are available, but 24-hour surgical services may not be available. C) Trauma and specialty surgical services are available; center provides trauma education to staff. D) Trauma and specialty surgical services are available; provides trauma and injury prevention education to community.
In which situation is the nurse not subject to liability?
a. The nurse correctly administers first aid at the scene of an automobile accident. The patient, however, sustains permanent injuries. b. The nurse performs a procedure, but does not document it. The patient claims injuries because the procedure was not performed. c. The nurse performs a new procedure for which she has not received training. The patient claims injury. d. The nurse wraps tape around a frayed elec-trical cord. The equipment malfunctions and the patient claims injuries.
A nurse caring for an elderly client who is in a coma and facing an inevitable death cautions the family that it is most important not to have inappropriate conversations near the client because:
1. Hearing may be the last sense "to go.". 2. It shows disrespect for the client. 3. Family members should get along. 4. It interferes with adequate care of the client.
The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. The nurse should explain to the mother that:
1. Physiologic jaundice is normal, and peaks at this age. 2. The newborn's liver is not working as well as it should. 3. The baby is yellow because the bowels are not excreting bilirubin. 4. The yellow color indicates that brain damage might be occurring.