After formulating the nursing diagnoses for a new patient, what is the nurse's next action?
a. Implement the nursing plan of care.
b. Complete the spiritual assessment.
c. Determine the goals and outcome criteria.
d. Design interventions to include in the plan of care.
C
Standard 3 refers to determining outcomes. Outcomes cannot be determined until the nursing assessment is complete and the nursing diagnoses have been formulated.
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A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this client?
A) Presence of acute pain and anxiety B) Tissue integrity and color of the operative site C) Respiratory status and airway clearance D) Self-esteem and body image
The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.
Which nursing considerations relate to the administration of lithium? (Select all that apply.)
a. Administer the medication on an empty stomach. b. Restrict fluids to 1000 mL daily. c. Draw frequent blood levels. d. Teach the importance of contraception while taking the drug. e. Teach the importance of avoid caffeine while taking the drug.
A client has been incarcerated for robbing a delivery person to obtain money for methamphetamine
During an assessment of the client, he states that he uses drugs to quiet the voices he hears in his head. Which of the following would be an appropriate nursing diagnosis for this client? A) Chronic Low Self-Esteem B) Risk for Violence C) Ineffective Coping D) Anxiety