The nurse listens as the physician informs the client of the diagnosis of colon cancer and explains the need to remove the colon and create an ileostomy. When the physician leaves, the nurse's priority diagnosis is:
1. Risk for Perioperative–Positioning Injury.
2. Risk for Disuse Syndrome.
3. Risk for Ineffective Coping.
4. Knowledge Deficit.
3. Risk for Ineffective Coping.
Rationale:
The client and family will require support to deal with their emotional response to learning the client has cancer and will undergo body-image changing surgery. Disuse syndrome and injury from positioning may be factors after surgery. Now is not the time to begin instructions because the client will most likely be unable to learn or concentrate on what the nurse is teaching.
You might also like to view...
The nurse is reading about a case in which Medicare fraud is suspected. Which of the following is true about fraud?
a. It is written information given to a third party that causes damage to someone's reputation. b. It is oral information given to a third party that causes damage to someone's reputation. c. It results from a deliberate deception intended to produce unlawful gain. d. It results from revealing confidential information without the person's permission.
The nurse is supervising care in the emergency department. Which situation most requires an intervention?
1. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer's solution running at 125 mL/hour 2. Spotting of pinkish-brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour 3. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20 4. Dark red bleeding at 30 weeks' gestation with normal vital signs; patient reports an absence of fetal movement
Following ergonomic principles, how will you advise your circulating nurse to set up the operating room?
You are the instrument nurse for a laparoscopic hemicolectomy and are organising equipment for the procedure. What will be an ideal response?
The nurse has completed an assessment and found that the client has "an activity and exercise abnormality." This type of wording indicates that which of the following organizing formats has been used?
1. Review of systems 2. Nursing health history 3. Gordon's functional health patterns 4. Biographical information database