The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is:
a. altered nutrition, less than body requirements.
b. body image disturbance.
c. decreased cardiac output.
d. fluid volume deficit.
B
Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result. Nutritional support is started early in management of the patient with burns, and there is no indication that this patient has a nutritional deficit. Nursing care plan priorities would also continue to focus on nutritional needs to optimize healing. Decreased cardiac output and fluid volume deficit should not be priority concerns during the wound closure phase of burn wound management by grafting.
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When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient?
a. "Are you of the Christian faith?" b. "Do you want to see a medicine man?" c. "How often do you seek help from medical providers?" d. "What cultural or spiritual beliefs are important to you?"
Helicobacter pylori is implicated as a causative agent in the development of duodenal or gastric ulcers. What teaching should the nurse practitioner plan for a patient who has a positive Helicobacter pylori test?
A. It is highly contagious and a mask should be worn at home. B. Treatment regimen is multiple lifetime medications. C. Treatment regimen is multiple medications taken daily for a few weeks. D. Treatment regimen is complicated and is not indicated unless the patient is symptomatic.
The nurse preceptor recognizes the new nurse's ability to determine patient safety risks when which behavior is observed?
a. Checking patient identification once every shift b. Multitasking by gathering two patients' medications c. Disposing of used needles in a red needle container d. Raising all four side rails per family request
The client states, "I am using homeopathic remedies to help with my morning sickness." The nurse understands that the client is utilizing:
1. A complementary therapy. 2. An alternative therapy. 3. Traditional Chinese medicine. 4. Naturopathy.