A client who feels the urge to void after surgery is reluctant to get out of bed and walk to the bathroom with the nurse because of incisional pain. Which of the following is the most appropriate nursing diagnosis for this client?
1. Acute pain related to verbal complaints of incisional discomfort
2. Ineffective breathing pattern related to incisional discomfort
3. Urinary retention related to reluctance to ambulate to bathroom
4. Risk for urinary retention related to reluctance to ambulate to bathroom
ANS: 1
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a. Contact Adult Protective Services or hospital social work. b. Notify the provider that the client needs a tube feeding. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals.
The school nurse is completing a Continuous Quality Improvement Tool for School-based Health Centers. What should the nurse identify as sentinel events for high school students? (Select all that apply.)
1. Alcohol use. 2. Depression risk. 3. Risk for violence. 4. Sexually transmitted infections (STI). 5. After school employment hours.
A patient is frequently thirsty. To what should the nurse attribute this symptom?
a. Too much sodium and too much water in the body b. Too little sodium and too much water in the body c. Too much sodium and too little water in the body d. Too little sodium and too little water in the body
A nurse who is the manager of an ambulatory pediatric health care center is planning protocols for the routine health care visits of the children. Children at this care center have a high incidence of obesity
The nurse should ask all nurses to calculate the body mass index (BMI) for all pediatric clients at which age? 1. 12 months 2. 24 months 3. 36 months 4. 4 years