A pregnant client with a history of heart disease has come to the community-based prenatal clinic. Which of the following would the nurse see as an indication that the client's heart is not able to handle the additional workload of the pregnancy?
A) Capillary refill is less than 3 seconds. B) Feet and legs show significant swelling each evening. C) Blood pressure increases from 110/80 to 145/100. D) Crackles are heard in the lung bases.
D
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A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis?
A) Encourage the patient to conduct online research into colostomies. B) Engage the patient in the care of the ostomy to the extent that the patient is willing. C) Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D) Emphasize the fact that the colostomy is temporary measure and is not permanent.
You're discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?
A. "Now I can never get hepatitis again." B. "I can safely give blood after 3 months." C. "I'll never have a problem with my liver again, even if I drink alcohol." D. "My family knows that if I get tired and start vomiting, I may be getting sick again."
The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions?
A) Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good B) Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS patients may last for several months C) Promoting communication with the patient and family along with addressing end-of-life issues D) Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
When a client undergoing systemic chemotherapy reaches the nadir of treatment, priority care by the nurse should be directed toward
a. assisting the client to eat an adequate amount of food to maintain nutrition. b. enhancing the effects of chemotherapy by encouraging mild activity. c. improving the mental state of the client by using mental imagery. d. protecting the client from infection and bleeding.