The nurse assesses a patient with cirrhosis who is experiencing hypertension, edema, and shortness of breath. Which nursing diagnosis will the nurse establish?
1. Fluid Volume Deficit
2. Ineffective Tissue Perfusion
3. Fluid Volume Excess
4. Impaired Skin Integrity
3
Rationale 1: Hypotension and dry mucous membranes are associated with Fluid Volume Deficit.
Rationale 2: Ineffective Tissue Perfusion is an appropriate diagnosis for a patient experiencing cyanosis or tissue necrosis.
Rationale 3: Hypertension, shortness of breath, and edema are manifestations of fluid excess.
Rationale 4: Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this patient.
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A patient telephones a nurse to report the onset of muscle pain and weakness. The patient is taking gemfibrozil with a statin. The nurse should be concerned about the development of:
a. peripheral neuropathy. b. hypothyroidism. c. myopathy. d. hepatic disease.
A client with a history of breast cancer is admitted through the emergency department with shortness of breath, weakness, fatigue, and new lower extremity edema. The client's oxygen sa-turation is 88%
After stabilizing the client, which action by the nurse is most important? a. Obtain a list of the client's medications. b. Orient her to her room and surroundings. c. Place the client on intake and output. d. Assess the client's family cardiac history.
A nurse is working with a group of clients in a community center, all over the age of 85. This group is referred to as which of the following?
1. Young-old 2. Middle-old 3. Old-old 4. Elite-old
A mentally confused patient refuses a bath. You know that the patient's daughter is named as the attorney in the patient's durable power of attorney for health care, and the daughter has signed the consents for hospital treatment. You should
A. honor the refusal and not give the bath. B. return later and try to bathe the patient then. C. call the daughter and ask her what to do. D. force the patient to bathe.