After collecting data the nurse identifies diagnoses to guide the patient's care. Which diagnoses did the nurse document correctly? (Select all that apply.)
a. Diabetes
b. Acute pain
c. Pancreatitis
d. Activity intolerance
e. Impaired physical mobility
ANS: B, D, E
B. D. E. Acute Pain, Activity Intolerance, and Impaired Physical Mobility are nursing diagnoses. A. C. Diabetes and Pancreatitis are medical diagnoses.
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The nurse is caring for an adolescent client who has been non-adherent with the medical plan of care to treat Crohn disease
In order to increase adherent behavior, which complication associated with Crohn disease will the nurse include in the client's teaching plan? A) Vomiting B) Bowel perforation C) Intestinal obstruction D) Diarrhea
During a community service lecture, the nurse is instructing women on self breast examinations. One of the participants asks why her breasts become tender. Prior to explaining the cause of the pain, the nurse should ascertain whether:
A) The pain occurs prior to her menstrual period B) She has dimpling in any breast site C) She has given birth to children D) She exercises daily or occasionally
The Juarez family includes Maria, age 76, Juan, age 72, and three adult children. Maria has been managing a diagnosis of heart failure for approximately 10 years
Documentation suggests the family has had a great deal of stress with recent hospitalizations and caregiving in their home. The adult children voice their concerns about Maria's decision to complete an advanced directive. Which of the following demonstrate an insufficient understanding of family-focused nursing care and communication? 1. A nurse should make a statement such as, "Your family has had a great deal of distress lately; why don't you just let Maria make her own decisions." 2. A nurse's questioning techniques may help identify the family's beliefs and understandings about advanced directives. 3. A nurse should make a statement such as, "Your family has done a good job of caring for each other during this lengthy illness." 4. A nurse should attempt to clarify misunderstandings and share accurate information about the health status of the patient.
The nurse explains to the client scheduled to undergo a cardiac catheterization that the test involves the use of
A) A Doppler instrument to determine coronary blood flow B) A venous catheter to measure cardiac output C) High-frequency sound waves to detect coronary blood flow D) Radiopaque dye injected into an artery to visualize heart function