The nurse is caring for a Vietnamese-American admitted to the intensive care unit as a result of malnutrition. The patient is unable to walk because of his malnutrition,
and he has developed a pressure ulcer from lying in bed constantly without changing positions. The family believes that the patient is depressed and that is why he stopped getting up. When planning this patient's care, the nurse should:
a.
develop multiple nursing diagnoses.
b.
develop only one nursing diagnosis to aid in focusing.
c.
focus on the physical issues facing this patient.
d.
deal primarily with the patient's psychological needs.
ANS: A
Analysis of patient assessment data may yield several clusters of related data or cues. It is common to apply several nursing diagnostic statements to one patient. This is especially true for acutely ill patients with multiple problems related to complex physical or psychological needs.
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ANS:
When assessing a family for functional versus dysfunctional characteristics, which is a dysfunctional target symptom the nurse should identify?
a. An adolescent who is failing math b. A teenage daughter who is 6 months pregnant c. A spouse who maintains family peace at any price d. A young adult who is working full-time as a laundry worker
A resident is blind. Which measure is unsafe for the person?
a. Rearranging the person's furniture and equipment b. Keeping hallways and walkways free of equipment and clutter c. Keeping the person's call light within reach d. Letting the person perform self-care as able
Which assessment finding would suggest that a child's postoperative feeding schedule following pyloric stenosis surgery should be slowed?
What will be an ideal response?