An adult tells the nurse, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter told me she's quitting college and moving in with her boyfriend."
What is the priority nursing diagnosis?
a. Fear, related to impending surgery
b. Deficient knowledge, related to breast lesion
c. Ineffective coping, related to perceived loss of daughter
d. Impaired verbal communication, related to spousal estrangement
ANS: C
This nursing diagnosis is the priority because it reflects the precipitating event associated with the patient's crisis. Data are not present to make the other diagnoses of Deficient knowledge, Fear, or Impaired verbal communication.
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The nurse is providing discharge teaching for a patient with a large carbuncle on the back of the neck
The physician performs surgical incision and drainage under a local anesthetic and prescribes oral antibiotics and daily dressing changes with topical antibiotic ointment. A prescription for acetaminophen with codeine is also provided. Which of the following statements indicates further teaching is necessary? a. "I will need to increase my fluid and fiber intake to prevent constipation while I'm taking the pain medication." b. "Once the swelling and redness are gone, I can stop taking the antibiotics." c. "I should wash the area gently with antibacterial soap before applying a new dressing." d. "Covering my pillow with plastic and cleaning it every day will help prevent additional infection."
An hour after a patient has a thoracentesis, the patient's oxygen saturation is 88, and respiratory rate is 34 . What actions by the nurse are priorities?
a. Raise the head of the bed and call the nursing supervisor. b. Give oxygen to the patient and notify the physician. c. Look at the chest excursion and notify respiratory therapy. d. Open a chest tube insertion kit and notify the patient's family.
Triangulation is the use of multiple sources or referents to draw conclusions about what constitutes the truth
A) True B) False
A community/public health nurse refers to Healthy People 2020 when providing community-based education. What is the significance of this document?
a. It clarifies the importance of hospitals in community-based care. b. It expands on what kinds of care the federal government is willing to fund. c. It explains the federal goals for improved health of the nation. d. It provides a guide for nurses when they speak with the public. e. It specifies how federal health care funds will be spent. f. It emphasizes appropriate nursing interventions when direct client care is provided.