The nurse is initiating care for a client diagnosed with burns to the chest, back, neck, and face. For this client, which of the following nursing diagnoses would receive the highest priority?
1. Disturbed body image
2. Impaired skin integrity
3. Ineffective airway clearance
4. Risk for infection
3
The highest priority would be to maintain the airway with adequate oxygenation and ventilation. The other nursing diagnoses would not be the first priority.
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A 14-year-old girl came with her family to the clinic as her father picked up his medication. The girl became anxious and said she had to go home soon to clean the house and start dinner. Which of the following would the nurse most likely suspect from this interaction?
a. As Freud pointed out, girls try to take over the wife role with their dad. b. The girl did not want to admit her dad was a drug addict and was trying to get away from an uncomfortable environment. c. The girl is taking on the role of hero with responsibility for caretaking functions. d. The girl was afraid she would be seen with her dad, a known drug addict, in a public place.
A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug?
A) Metoclopramide (Reglan) B) Omeprazole (Prilosec) C) Lansoprazole (Prevacid) D) Famotidine (Pepcid)
When teaching an older patient about diet therapy, the nurse plans to assess for barriers to adherence, including which factors? (Select all that apply.)
a. Lifelong habits b. Cultural influences c. Finances d. Dependency e. Inability to learn
The nurse is assessing a client who is diagnosed with borderline personality disorder. Which of the following statements made by the client indicates the client is at risk for self-injurious behavior?
A) "I have felt so down lately. I don't enjoy doing anything anymore." B) "I am so worried about what is going to happen to me." C) "When I feel extremely anxious, it is like my mind goes somewhere else." D) "It is almost as if as soon as I think of doing something, I immediately do it."