Which nursing diagnosis should the nurse set as a priority for a laboring client?
a. Risk for anxiety related to upcoming birth
b. Risk for imbalanced nutrition related to NPO status
c. Risk for altered family processes related to new addition to the family
d. Risk for injury (maternal) related to altered sensations and positional or physical changes
ANS: D
The nurse should determine which problem needs immediate attention. Risk for injury is the problem that has the priority at this time because it is a safety problem. Risk for anxiety, imbalanced nutrition, and altered family processes are not the priorities at this time.
You might also like to view...
A descendancy approach to a literature search is essentially the same as an author search
A) True B) False
What instruction should a nurse provide to a patient who has been diagnosed with stress incontinence?
a. "Restrict fluid intake to less than 1000 mL/day." b. "Avoid fluids such as tea, coffee, and co-la." c. "Delay voiding until you feel the urge to void." d. "Void no more often than every 4 hours."
A patient with second-degree burns is treated with silver sulfadiazine [Silvadene]
A nursing student asks the nurse about the differences between silver sulfadiazine and mafenide [Sulfamy-lon], because the two are similar products, and both contain sulfonamides. What does the nurse tell the student about silver sulfadiazine? a. It causes increased pain when the medica-tion is applied. b. It has a broader spectrum of antimicrobial sensitivity. c. It has antibacterial effects related to re-lease of free silver. d. It suppresses renal excretion of acid, causing acidosis.
What is the term used to define an unexpected event involving death or serious injury to a client?
a. incident c. sentinel event b. nosocomial effect d. malpractice