Routine hygiene care can provide an opportunity for the nurse to assess the client's level of activ-ity intolerance. Which of the following assessment questions is most likely to provide information that supports this nursing diagnosis?
1. "Will you need my help to take a bath?"
2. "Does taking a bath or shower cause you any pain?"
3. "Can you bathe and dress yourself without needing help?"
4. "Do you find yourself getting tired before you're finished bathing?"
ANS: 4
The remaining options are not as directed towards activity intolerance since a positive response to any of them may be a result of causes other than weakness.
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The nursing diagnosis for a patient with mania is Imbalanced nutrition: less than body requirements related to caloric intake insufficient to balance with hyperactivity as evidenced by 5 lb weight loss in 4 days. Select the most appropriate outcome
The patient will: a. reduce hyperactivity within 1 week. b. drink four high-calorie, high-protein supplements per day. c. consistently wear appropriate attire for age and sex within 1 week. d. display consistently nonviolent behavior toward others within 1 week.
The new mother has decided not to breastfeed the baby. To suppress the milk supply, the nurse recommends that the mother:
a. pump the breasts to remove milk. b. apply warm, moist compresses. c. restrict oral fluids. d. apply a firm bra and ice packs.
Which preventive factor should a nurse teach clients with rhinitis?
A) Avoid clearing the throat. C) Get adequate rest and sleep. B) Use a straw to drink fluids. D) Avoid carbonated fluids.
A 44-year-old patient with type 1 diabetes is brought to the emergency department with ketoacidosis. The nurse should immediately prepare to administer
a. subcutaneous insulin. b. intravenous normal saline in large quantities. c. dextrose 50% plus thiamine. d. glucagon.