The nurse is developing a care plan for a patient who is taking an anticholinergic drug. Which nursing diagnosis would be appropriate for this patient?
a. Diarrhea
b. Urinary retention
c. Risk for infection
d. Disturbed sleep pattern
ANS: B
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The patient with a laryngectomy needs an evaluation of his ability to perform self-care of the stoma prior to discharge. Which patient action would demonstrate safe and appropriate stoma care?
A) The patient has the nurse clean his or her tracheostomy tube. B) The patient carefully removes crusting from around the stoma. C) The patient tells the nurse that he has enrolled in swimming lessons. D) The patient vigorously cleans the crusts from into his stoma.
A 32-year-old man who has a body mass index of 32 (morbidly obese) is considering bariatric surgery. In the time leading up to this surgery, which of the following nursing diagnoses will be the primary focus of interventions?
A) Knowledge deficit related to the implications of bariatric surgery B) Altered growth and development related to obesity C) Risk for injury related to obesity D) Spiritual distress related to low body image
A patient reports an inability to sleep because of too much noise and light, even though the environment is quiet with soft lighting. The nurse knows such reports support dysfunction of which organ?
a. Basal ganglia b. Pituitary gland c. Substantia nigra d. Reticular activating system
Which statement is true of toxic shock syndrome?
a. It is a sexually transmitted infection. b. Rash, fever, and flulike symptoms are typical. c. The blood pressure rises to dangerous levels. d. It is caused by Escherichia coli.