An elderly client reports difficulty reading and driving, especially at night. He also reports he has difficulty getting up and down his stairs because "they seem to blend together." Which nursing diagnosis is most appropriate for this client?
a. Sensory/perceptual alterations: sensory deprivation related to therapeutic isolation.
b. Risk for injury: falls related to declining vision associated with aging.
c. Sensory/perceptual alterations: sensory overload related to hospitalization.
d. Altered thought processes related to hospitalization and aging.
ANS: B
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Complications of ETT tubes include (Select all that apply.)
a. tracheoesophageal fistula. b. cricoid abscess. c. tracheal stenosis. d. tube obstruction. e. tube displacements.
A client of Vietnamese background is admitted to the unit after a hysterectomy. She has an order for clear liquids. When her tray is brought to her, she refuses the lime Jell-O. Which response by the nurse is most appropriate?
a. "I don't blame you. I don't like lime Jell-O either." b. "Tell me about your cultural beliefs to best help you." c. "Why don't you want to eat the lime Jell-O?" d. "It is important for you to eat so that you will heal."
Effectiveness of a given type of therapy is BEST documented by:
a. client satisfaction surveys b. outcomes measured by the therapists c. reassessments by the referral sources d. empirical research studies
A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An ap-propriate action would be to:
1. Take the rectal temperature 2. Take the oral temperature as planned 3. Have the child rinse out the mouth with warm water 4. Wait 20 minutes before assessing the oral temperature