An infant is hospitalized with RSV bronchiolitis. What is the priority nursing diagnosis?
a. Fatigue related to increased work of breathing
b. Ineffective breathing pattern related to airway inflammation and increased secretions
c. Risk for fluid volume deficit related to tachypnea and decreased oral intake
d. Fear and/or anxiety related to dyspnea and hospitalization
ANS: B
An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.
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The correctional mental health nurse assesses a new prisoner who is beginning his incarceration for
committing a sex crime. The prisoner speaks in a low voice, is tearful, and tells the nurse that his life may as well be over as there is no hope that he will ever be able to fit into society after he is released from prison. He states his family has disowned him and that wherever he goes his reputation will follow him. The priority intervention would be to a. arrange to meet with him weekly to discuss feelings. b. offer to contact his family to speak of his remorse. c. advise the guards to place him in solitary confinement. d. arrange to implement suicide precautions.
Patients experiencing emotional or physical pain may exhibit similar signs, such as a pained facial expression. Which sign is most likely to indicate emotional pain rather than physical pain?
a. labored breathing and speech, wheezing, and shortness of breath b. facial grimacing, crying, and moaning c. diaphoresis, tachycardia, and physical protection of the painful area d. excessive nail-biting, tearfulness, and avoidance of eye contact
The older adult long-term care resident with dementia becomes agitated each evening after supper because he "hasn't walked his dog
" The nurse plans to intervene by doing the fol-lowing (prioritize these options from the most simple to the most complex): 1. Remind him that his dog is not in the facility. 2. Help him draw a dog on paper and carry it with him. 3. Give him a small stuffed dog. 4. Reorient resident to time and place. 5. Ask his daughter to bring the dog to the facility.
A client who had a thrombotic stroke finished receiving intravenous rt-PA therapy at 10:00 AM on Sunday. Sunday afternoon the physician writes an order to start Coumadin and Plavix that evening. The most appropriate action by the nurse would be to
a. call the physician and clarify when the medications should be given. b. consult with the pharmacist about giving both medications together. c. give the Coumadin at 5:00 PM because that is the standard administration time. d. provide appropriate education and administer the medications as ordered.