When the nurse is caring for a client with progressive systemic sclerosis (PSS), the high-est-priority nursing diagnosis would be
a. Constipation.
b. Disturbed Thought Processes.
c. Risk for Imbalanced Body Temperature.
d. Risk for Impaired Skin Integrity.
D
Nursing interventions are directed at the control of manifestations. One of the major areas of concern is skin care to prevent breakdown and ulceration. Clients with PSS can have gastrointes-tinal disturbances such as constipation or diarrhea. They also have to avoid becoming cold. Dis-turbed Thought Processes is not a typical nursing diagnosis for the client with PSS.
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The children of a widow confer with the bereavement nurse because their mother persists in
repeatedly telling people the details of finding her husband not breathing, performing CPR, and going to the emergency department with him by ambulance and seeing him pronounced dead. The family are concerned that this is traumatic to those who have to hear the story and ask what they can do. The nurse should counsel the family that a. they can interpret their feelings to their mother and ask for a change in behavior. b. the retelling should be limited to once daily to avoid unnecessary stimulation. c. repeating the story and her feelings is a helpful and necessary part of grieving. d. retelling of memories is to be expected as part of the aging process.
The home health care agency that receives federal funds desires to hire a new home health care aide. This aide will provide direct and hands-on care to patients. Which person would meet federal requirements for that position?
1. A nursing assistant who has on-the-job training at a nursing home 2. A nursing assistant who completed a training and competency evaluation program 3. A nursing assistant who has on-the-job training at a hospital 4. A second-semester student enrolled in a registered nursing program
The nurse prepares to administer an IV piggyback of 75 mL of medication to infuse in 30 minutes with an infusion set of 35 gtt/mL. What should the gtt/min be set for?
1. 42 gtt/min 2. 44 gtt/min 3. 87.5 gtt/min 4. 88 gtt/min
A specific test is one that has the ability to:
a. correctly identify those who have the dis-ease. b. correctly identify those who do not have the disease. c. be exclusively used to make a diagnosis. d. exclude competing explanations for another test finding.