The appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions is that the patient will:
a. increase intake to 1000 mL daily to liquefy secretions.
b. cough more frequently within 3 days.
c. breathe better within 3 days.
d. perform deep-breathing exercises four times daily.
A
The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within three days is too vague.
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The nurse is interviewing a client who is 36 weeks pregnant. Which client statement would require immediate intervention by the nurse?
1. "I have to get up during the night to void." 2. "I have not felt the baby move today." 3. "I am leaking a yellowish fluid from my breasts." 4. "I have been taking Tylenol (acetaminophen) for my backaches."
Neuropathic pain originates in the:
a. skin. b. mucous membrane. c. peripheral and/or central nervous systems. d. blood vessels.
Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?
a. A nurse is responsible for breaking silences. b. Patients withdraw if silences are prolonged. c. Silence can provide meaningful moments for reflection. d. Silence helps patients know that what they said was understood.
Which health care professionals have the greatest control over the level of sensory input in the hospital?
1. Physicians 2. Administrators 3. Nurses 4. Planners