The client is a slim but well-nourished 72-year-old who broke a hip 2 days ago. The client underwent hip pinning surgery this morning and will be confined to bed for several days until able to ambulate
The nurse helps the client turn in bed frequently to reduce pressure on bony prominences and assists the client with elimination needs. What are the most appropriate nursing diagnoses for this client?
1. Feeding self-care deficit and Impaired skin integrity
2. Impaired skin integrity and Toileting self-care deficit
3. Toileting self-care deficit and Risk for impaired skin integrity
4. Risk for impaired skin integrity and Feeding self-care deficit
ANS: 3
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A client is admitted to the inpatient mental health unit with Asperger's syndrome. Which of the following assessment parameters would be most important for the nurse to observe?
A) Clumsiness in motor activities B) Hallucinations and delusions C) Letter reversal D) Lack of interest in peer relationships
A nurse who has been a longtime employee of a hospital, providing bedside care to clients, was seriously injured and is paralyzed from the shoulders down, with limited use of the upper arms
Through rehabilitation, the nurse is able to mobilize with a wheelchair and has no cognitive or psychological deficits. The nurse wants to return to the same position held prior to the injury. Under the guidelines of the ADA, the hospital: 1. Is required to accommodate the nurse. 2. Must find another job for the nurse. 3. Could claim undue hardship to accommodate this nurse. 4. Will have to terminate the nurse's employment.
During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?
A) Nail beds B) Sclera C) Palms D) Oral mucosa
If you were counseling SR about her diet and she insisted on remaining a vegan, what recommendations would you give her to improve her nutritional intake? What animal products might she include in her diet that the consumption of which would actually help preserve the animals from which the products are derived?