The nurse has completed the admission assessment for a client admitted to the hospital's sub-acute care unit. Of the following nursing diagnoses identified by the nurse, which one takes the highest priority?
a. Social isolation
b. Risk for injury
c. Adjustment, impaired
d. Communication, impaired verbal
B
The nursing diagnosis Risk for injury is the highest priority. Safety is always the most important consideration.
The nursing diagnosis Social isolation is not the highest priority.
The nursing diagnosis Adjustment, impaired is not the highest priority.
The nursing diagnosis Communication, impaired verbal is not the highest priority.
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a. Focus phase b. Announcement phase c. Adjustment phase
A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the most appropriate response for the nurse to make when the child asks, "Why do you have to wear a gown and mask when you are in my room?"
a. "Nurses and doctors wear gowns and masks because you have a condition that could be spread to others." b. "The gown and mask are to protect you because you could get an infection very easily." c. "I'm wearing this because there are a lot of bacteria in the hospital." d. "I might look scary but you won't need this after you have had medication for 24 hours."
Stage 1 hypertension with no cardiovascular risks is treated with lifestyle modifications
Indicate whether the statement is true or false.
While a patient is paralyzed with neuromuscular blockers, which assessment finding would the nurse expect?
1. Essentially unconscious 2. Heavily sedated but conscious 3. Stuporous but can be aroused 4. Remains conscious