The nurse is making a home visit to a client who had a cesarean birth 3 days ago. Assessment reveals that she is complaining of intermittent pain, rating it as 8 on a scale of 1 to 10 . She states, "I'm pretty tired
And with this pain, I haven't been drinking and eating like I should. The medication helps a bit but not much. My mom has been helping with the baby.". Her incision is clean, dry, and intact. Which nursing diagnosis would the nurse identify as the priority for this client? A) Impaired skin integrity related to cesarean birth incision
B) Fatigue related to effects of surgery and caretaking activities
C) Imbalanced nutrition, less than body requirements, related to poor fluid and food intake
D) Acute pain related to incision and cesarean birth
D
Feedback:
The client reports a pain rating of 8 out of 10 and states that the medication is helping only a bit. She also mentions that the pain is interfering with her ability to eat and drink. Therefore, the priority nursing diagnosis is acute pain related to incision and cesarean birth. Her incision is clean, dry, and intact, so impaired skin integrity is not the problem. She is fatigued, but her complaints of pain supersede her fatigue. Although her nutritional intake is reduced, it is due to the pain.
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Which assessment should the nurse perform last when examining a 5-year-old child?
a. Heart b. Lungs c. Abdomen d. Throat
The nurse understands that home health care is provided to clients who are:
A) chronically ill, disabled, or recuperating. B) acutely ill. C) unable to afford hospitalization. D) not covered by medical insurance.
The nurse recognizes that which of the following assessment observations of a comatose client has the greatest implication?
1. Both arms are extended and adducted and with the palms facing down. 2. Arms, wrist, and fingers are flexed and adducted. 3. Muscles of the entire upper extremities are flaccid bilaterally. 4. Fasciculational twitching occurs in the small muscle groups of both arms.