Which of the following nursing diagnoses would have the highest priority?
a. Ineffective Coping c. Ineffective Breathing Pattern
b. Risk for Impaired Skin Integrity d. Alterations in Urinary Output
C
One of the most common methods of selecting priorities is the use of Maslow's hierarchy of needs, which requires that life-threatening diagnoses be given more urgency that non-life-threatening diagnoses. Once the basic physiological needs are met, the nurse can consider needs on the next level of the hierarchy and so on up the hierarchy until all of the patient's nursing diagnoses have been prioritized.
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The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult?
A) Decreased left ventricular ejection time B) Decreased connective tissue in the SA and AV nodes and bundle branches C) Thinning and flaccidity of the cardiac values D) Widening of the aorta
A client with an antisocial personality disorder is caught shoplifting and as part of his probation agreement is required to spend 1 month at a psychiatric facility for treatment
Select the inter-vention by the nurse that has the highest probability of success in treating this disorder. a. Using daily one-on-one sessions with the nurse b. Placing the client in group peer therapy with strong external controls c. Initiating treatment with antianxiety me-dications d. Quickly placing the client in isolation when he acts out
Which statement by a patient who is prescribed heparin indicates to the nurse the need for additional teaching?
a. "I'll be sure to have my follow-up aPTT drawn when the prescriber tells me to." b. "I will not take over-the-counter drugs that contain aspirin." c. "I will get plenty of exercise playing soccer." d. "I'll tell my prescriber if I have headaches."
A child being treated at home for acute glomerulonephritis has a convulsion. What should the nurse recommend the caregiver do at this time?
A) Weigh the child in the same clothes she had been weighed in the day before and report the two weighs to the nurse B) Take the child's blood pressure and report the findings to the nurse C) Give the child a diuretic and report back to the nurse in a few hours D) Give the child fluids and report back to the nurse in a few hours