What nursing diagnosis would be most appropriate for a patient with pemphigus?
a. Imbalanced Nutrition: Less Than Body Requirements
b. Risk for Infection
c. Fluid Volume Excess
d. Self-Care Deficit: Skin Care
ANS: B
The major complication of pemphigus is a secondary bacterial infection. Nutrition and self-care deficit would be determined based on assessment findings. Fluid volume deficit would be more likely than excess because of the oozing blisters.
You might also like to view...
The nurse is caring for a patient who may have had an acute myocardial infarction. Part of the evaluation includes analysis of serum cardiac markers or enzymes. What pattern of elevation is most likely to indicate an acute myocardial infarction?
A) CK-MB was elevated immediately and returned to normal in 36 hours. B) Troponin I was elevated immediately and returned to normal in 48 hours. C) Troponin T was elevated immediately and returned to normal in 18 hours. D) Myoglobin was elevated immediately and returned to normal in less than 24 hours.
The mother of a severely and persistently mentally ill client says to the nurse "Why are you getting
my daughter involved in that vocational rehabilitation program? She is too sick to ever be able to hold a job.". The best reply for the psychiatric rehabilitation nurse would be a. "We do this to be eligible for federal funding for our programs.". b. "Are you concerned that we are trying to make Anna too independent?" c. "If you think the program is detrimental to Anna, we can postpone it for a time.". d. "Most clients are capable of employment at some level, competitive or sheltered.".
The nurse is caring for a 2-year-old boy with hemophilia. The parents are worried that he may become infected with hepatitis or HIV through a blood product transfusion. How should the nurse respond?
A) "It is common for parents to fear the worst, but the factor will help your child lead a normal life." B) "There are risks with any treatment using blood products, but it is very low." C) "Factor replacement is very expensive and bleeding episodes can cause you to miss work, creating a financial strain." D) "Since heat treatment began, there have been no reports of virus transmission since 1986."
Doing an assessment of the necessity of care before giving service is referred to as a
a. Concurrent audit b. Retrospective audit c. Prospective utilization review d. Retrospective utilization review