Which of the following statements appropriately identifies an at-risk nursing diagnosis for a 78-year-old woman who is confined to bed?
A) Ineffective airway clearance related to bed rest
B) Immobility related confinement to bed
C) Potential for pneumonia related to inactivity
D) Risk for impaired skin integrity related to bed rest
Ans: D
You might also like to view...
A patient who changes her own skin lesion dressings tells the nurse that she developed a new skin lesion on another body part. The nurse realizes this patient is most likely describing which mode of transmission?
1. Vector-borne 2. Vehicle 3. Indirect contact 4. Direct contact
A nurse is classifying the pregnancy history of a woman who has had five pregnancies: three full-term, one preterm, and one abortion. How would the nurse document this information on the patient chart?
A) G4 P3115 B) G5 P3114 C) G5 P3115 D) G5 P1135
The nurse on a postoperative care unit is assessing the quality of the client's pain. In order to ob-tain this specific information about the pain experience from the client, the nurse should ask:
1. "What does your discomfort feel like?" 2. "What activities make the pain worse?" 3. "How much does it hurt on a scale of 0 to 10?" 4. "How much discomfort are you able to tolerate?"
What major complication of TLS is H.J. at risk for and why?
What will be an ideal response?