The client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on a thorough understanding of personality disorders, the nurse would select which nursing diagnosis as the priority?
1. Ineffective coping
2. Chronic low self-esteem
3. Risk for self-mutilation
4. Social isolation
3
Rationale: Clients with borderline personality disorder are most often hospitalized because of impulsive attempts at self-mutilation or suicide. The nursing intervention of constant close ob-servation is usually initiated to protect the client from impulsive behavior. Therefore, "risk for self-mutilation" is the priority.
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The nurse is evaluating the parent's understanding of teaching related to environmental control for their child's asthma management. Which statement by the parents indicates that they understand the teaching?
1. "We're glad the dog can continue to sleep in our child's room." 2. "We'll keep the plants in our child's room dusted." 3. "We'll be sure to use the fireplace often to keep the house warm in the winter." 4. "We will replace the carpet in our child's bedroom with tile."
The nurse is inspecting the scrotum and testes of a 43-year-old man. Which finding would require additional follow-up and evaluation?
a. Skin on the scrotum is taut. b. Left testicle hangs lower than the right testicle. c. Scrotal skin has yellowish 1-cm nodules that are firm and nontender. d. Testes move closer to the body in response to cold temperatures.
When auscultating the lungs of a child with asthma, the nurse would expect to note which of the following most common symptoms?
A) Shallow respirations B) Increased A-P diameter C) Bilateral wheezes D) Rhonchi in the lower bases
Which measurement is not indicated for a 4-year-old well-child examination?
a. Blood pressure b. Weight c. Height d. Head circumference