After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses?
1. The ones that the nurse is licensed to treat
2. The ones that address other health professionals' interventions
3. The ones that focus on the client's primary illness
4. The ones that have standardized care available
Correct Answer: 1
Rationale 1: The domain of nursing diagnoses includes only those health states that nurses are educated on and licensed to treat. A nursing diagnosis is a judgment made only after data collection. Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth.
Rationale 2: A nursing diagnosis, although familiar to other health care professionals, is nursing focused.
Rationale 3: The nursing diagnosis statement is specific to nursing and nurses and does not include the medical diagnosis.
Rationale 4: The nursing diagnosis, like the plan of care, is specific to each individual client and the client's situation.
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A pregnant woman at 30 weeks gestation is in the CCU with severe eclampsia. She is experiencing pulmonary edema, severe oliguria, and hypotension and continues to have seizures
She is endotracheally intubated, supported by a mechanical ventilator, and is receiving intravenous magnesium sulfate at 3 g/hr; the serum magnesium level is 8 mg/dL. She is beginning spontaneous early labor. What is the most important intervention? A) Administer medication to delay the onset of labor, as is preterm. B) Increase the dose of magnesium sulfate to control seizures. C) Facilitate delivery of the baby, as eclampsia is worsening. D) Administer high-dose diuretics for the pulmonary edema.
Interpersonal communication that recognizes an individual's human characteristics and addresses the health care issue with dignity and respect is called:
a. dehumanizing. b. humanizing. c. persuasion. d. bargaining.
The young client has a history of multiple allergies, and the physician prescribed epinephrine (EpiPen) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure."
What is the best response by the nurse? 1. "There are many kinds of shock that also include infection, nervous system damage, and loss of blood.". 2. "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood.". 3. "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure.". 4. "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure.".
Explicit statements of how a variable will be measured, such as using a rating scale to collect quantitative data regarding pain, are called
a. conceptual definitions b. empirical indicators c. operational definitions d. theoretical framework