Which of the following nursing diagnoses would the nurse include in the plan of care for a client with a catheter embolism?
1. Alteration in Comfort
2. Impaired Skin Integrity
3. Fluid-Volume Deficit
4. Ineffective Coping
Alteration in Comfort
Rationale: Alteration in Comfort is the correct diagnosis because the client will often experience chest pain with catheter embolism. Impaired Skin Integrity is incorrect because the catheter has broken inside the client's vasculature and skin integrity will not be altered. Catheter embolism does not reflect signs of fluid loss; it will reflect signs of decreased vascular perfusion. Ineffective Coping is incorrect because the manner in which a client copes does not impact this life-threatening emergency.
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A health care facility has experienced a recent outbreak of infection that is attributable to an antibiotic-resistant microorganism. Which type of client is most likely at increased risk for infection?
A) Adult B) Child C) Elderly D) Pregnant
The nurse is completing a bed bath for a dependent adult male client. During the perineal care, the client has an erection. The nurse should:
1. Continue with the perineal care 2. Tell the client it's okay and just to relax 3. Ask the client to try and do the care as well as he can 4. Defer the care until a little later in the bath
A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for "not knowing enough to give me pain medicine when I need it."
Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation.
Tissue plasminogen activator (TPA) is contraindicated in hemorrhagic cerebral vascular accidents
Indicate whether the statement is true or false