Which of the following nursing diagnoses is a priority for the client with autonomic dysref-lexia?
A. Impaired Adjustment related to depression
B. Self-care Deficit related to spinal cord injury
C. Impaired Physical Mobility related to paraplegia
D. Impaired Urinary Elimination related to neurogenic bladder
D
For clients with spinal shock, autonomic dysfunction causes an areflexic bladder, leading to uri-nary retention and neurogenic bladder.
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While percussing a patient's left lung, the nurse detects a dull percussion note. How would the nurse interpret this finding?
1. The patient has hepatomegaly. 2. The patient might have fluid in the lung, which could indicate an infection. 3. The patient has emphysema. 4. The patient has normal lungs.
When performing catheter care on a male patient,
A) cleanse from the shaft of the penis to the meatus. B) cleanse from the meatus of the penis to the shaft. C) cleanse the distal two inches of the penis only. D) begin at the scrotum and wash up the shaft.
The patient refuses to take off her diamond wedding band prior to going to the operating room. What action should the nurse take first?
a. Document the patient's refusal to remove the jewelry. b. Tape the ring to finger, covering the ring. c. Request that the patient sign a waiver to release the hospital from responsibility. d. Alert the surgery team to the presence of the jewelry.
A 30-year-old electrician experienced a small abrasion on his knee while working 6 days ago. The wound has failed to heal, and the area surrounding the wound is now swollen, reddened, and painful
The man has been diagnosed with cellulitis and is now being treated with IV antibiotics. What should the nurse teach the patient to facilitate healing? A) "Try to keep your knee elevated above the level of your heart." B) "I'll give you an ice pack, which you should try to apply once per hour." C) "You'll likely be given an antibiotic ointment to take home after you're discharged from the hospital." D) "I'll be applying a compression stocking over your knee to help it heal."