A Native American patient describes a difficult childhood and dropping out of high school. The patient abused alcohol as a teenager to escape feelings of isolation but stopped 10 years ago. The patient now says, "I feel stupid. I've never had a good job
I don't help my people." Which nursing diagnosis applies?
a. Risk for other-directed violence
b. Chronic low self-esteem
c. Deficient knowledge
d. Social isolation
ANS: B
The patient has given several indications of chronic low self-esteem. Forming a positive self-image is often difficult for Native American individuals because these indigenous people must blend together both American and Native American worldviews. No defining characteristics are present for the other nursing diagnoses.
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A student nurse asks why brushing clients' teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?
a. "It mechanically removes biofilm on teeth." b. "It's easier to clean all surfaces with a brush." c. "Oral care is important to all our clients." d. "Toothbrushes last longer than oral swabs."
At the conclusion of a stress echocardiogram it was determined that the patient has dyskinesis. The nurse would reinforce which explanation of this finding?
1. The patient's heart moves too slowly. 2. The patient's heart wall moves very quickly to impulses. 3. The patient's heart wall moves opposite from normal. 4. A portion of the patient's heart does not move at all.
Which of the following would be least appropriate for a person with heart failure to help obtain adequate nutrition?
1. Providing liquid supplements between meals 2. Encouraging light exercise before meals 3. Selecting easily digested foods 4. Avoiding large meals
How much weight should this patient gain during pregnancy?
A 32-year-old attorney comes to your office for her second prenatal visit. She has had two previous pregnancies with uneventful prenatal care and vaginal deliveries. Her only problem was that with each pregnancy she gained 50 lbs (23 kg) and had difficulty losing the weight afterward. She has no complaints today. Looking at her chart, you see she is currently 10 weeks pregnant and that her prenatal weight was 130 lbs (59 kg). Her weight today is 134 lbs (60.9 kg). Her height is 5'4”, giving her a BMI of 22. Her blood pressure, pulse, and urine tests are unremarkable. The fetal heart tone is difficult to find but is located and is 150. While you give her first trimester education, you tell her how much weight you expect her to gain. A) Less than 15 pounds (less than 7 kg) B) 15 to 25 pounds (7 to 11.5 kg) C) 25 to 35 pounds (11.5 to 16 kg) D) 30 to 40 pounds (12.5 to 18 kg)