A nursing instructor explains to students that the ____________________ list contains nursing diagnoses that are standardized and arranged with the primary topic first, followed by modifiers
Fill in the blank with correct word.
ANS:
NANDA-I
The NANDA-I list contains nursing diagnoses developed and approved by the North American Nursing Diagnoses Association–International. The list is arranged with the primary topic first, and then modifiers follow.
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The nurse identifies the diagnosis Risk for Impaired Skin Integrity as applicable for a client with heart failure. Which assessment finding supports the use of this diagnosis for the client?
A) Shortness of breath with ambulation B) Productive cough C) + 3 pitting edema both feet D) Heart rate 104 and regular
A patient with multiple sclerosis is admitted to the unit. When the nurse assesses the patient, he notes that the patient is demonstrating involuntary rhythmic eye movements
What term will the nurse use when documenting these involuntary oscillations of the eye? A) Vertigo B) Tinnitus C) Nystagmus D) Dizziness
A nurse is teaching a nursing student how to care for patients in the perioperative period. Which statement by the student about preventing postoperative infections indicates a need for further teaching?
a. "Applying hexachlorophene to the opera-tive site preoperatively will help prevent infection." b. "It is important to ensure that all surgical instruments have been sterilized appro-priately." c. "Operating room personnel should all perform a presurgical scrub with antimi-crobial soap." d. "Preventing contamination by microor-ganisms in the environment is the most important perioperative measure."
A patient with left-sided heart failure is hospitalized with pulmonary edema. The nurse providing this patient's care would consider which physiology when explaining this disorder to the patient's family?
1. The normally high-pressure pulmonary circuit can damage lung tissue and cause pulmonary edema. 2. Since pulmonary veins have no valves, blood can back up into the lungs causing pulmonary edema. 3. The oxygen-rich blood that enters the pulmonary circuit tends to increase pressures in the tissue, causing pulmonary edema. 4. The arteries of the pulmonary circuit are single layer.