The nurse is considering a risk diagnosis for a client. A risk diagnosis can be applied when:
a. there is a recognized vulnerability to exhibit a problem, but the response has not manifested itself.
b. the state of being healthy may be enhanced by nursing interventions with the individual.
c. signs and symptoms are identified that define an existing problem.
d. the client indicates a desire to increase well-being.
ANS: A
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The nurse identifies clients likely to have clean wounds, including:(Select all that apply) Standard Text: Select all that apply
1. A client with multiple contusions 2. A client with a fresh surgical wound 3. A client who was in a motorcycle accident 4. A client who has purulent drainage 5. A client with a laceration from a knife
Which of the following assessment data will be most reflective of a client's pain response following open-heart surgery?
1. Family report of pain 2. Response from the client based on use of a pain tool 3. Observations of the client's behaviors while asleep 4. Measurement of vital signs
The final result(s) of the planning process is/are the
a. client goals c. nursing interventions b. expected outcomes d. nursing plan of care
A nurse is providing guidance to a group of parents of children in the infant-to-preschool age group
After reviewing statistics on the most common cause of death in this age group, the nurse includes information about prevention of which of the following? 1. Cancer by reducing the use of pesticides in the home 2. Accidental injury by reducing the risk of pool and traffic accidents 3. Heart disease by incorporating heart-healthy foods into the child's diet 4. Pneumonia by providing a diet high in vitamin C from fruits and vegetables