A client has had vision loss because of glaucoma. The nurse identifies the diagnosis: Anticipatory Grieving related to loss of vision. Which interventions does the nurse include in the client's plan of care? (Select all that apply.)
a. Allow the client to verbalize feelings.
b. Assess causative and contributing factors.
c. Examine the need for vocational rehabilitation.
d. Help the client explore avenues of support.
e. Instruct the client on home safety precautions.
A, B, C, D
All interventions are important for the client with significant vision loss; however, home safety precautions relates to the diagnosis Risk for Injury. Anticipatory grieving is an important diagnosis, as clients will most likely need to grieve the loss of normal vision and the need to make compromises and adaptations in daily life.
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A new mother is distressed and tearful about the elevated dome over her infant's posterior fontanelle. The nurse responds, "This condition will resolve itself in a few days." What is the cause?
a. Prolonged pressure against the partially dilated cervix b. Small leak of fluid through the posterior fontanelle c. Pressure of the forceps during delivery d. The effect of the vacuum extractor
Which of the following ABG values reflects compensation?
a. pH, 7.26; PaCO2, 55 mm Hg; HCO3–, 24 mEq/L b. pH, 7.30; PaCO2, 32 mm Hg; HCO3–, 18 mEq/L c. pH, 7.48; PaCO2, 30 mm Hg; HCO3–, 22 mEq/L d. pH, 7.38; PaCO2, 58 mm Hg; HCO3–, 30 mEq/L
The health care organization uses a barcoding system for the distribution of medications to clients. This system:
a. confirms the right client, drug, and dosage. b. produces data when stimulated by radio frequency energy. c. is not widely used. d. analyzes data to facilitate decision making.
An alert and oriented patient is to receive oral medication. Which does the nurse implement to administer the prescribed medication?
a. Evaluates the patient's ability to take the medications unassisted b. Leaves the medications on the breakfast tray for the patient to take later c. Asks the patient if she wants to hold the medications in her hand d. Holds the medicine cup to the patient's lips and tips it into the mouth