The client is a single parent being seen at an employee wellness clinic. The client tells the nurse he has three school-age children who participate in various activities
He states, "Every night, I am taking them to soccer practice, football practice, Girl Scouts. I have to fix dinner and then go over homework. I have no time for myself. I am so tired." The client exhibits tremors of his hands. Blood pressure is 140/88 mm Hg, heart rate is 98 beats/minute, and respirations are 30 breaths/minute. Data best supports which of the following nursing diagnoses?
A) Stress Overload related to single parenting
B) Defensive Coping related to inability to appraise stressors
C) Hopelessness related to multiple responsibilities
D) Disturbed Sleep Pattern related to anxiety
Ans: A
The client is stating his stressors and a reaction to the stressor when he states, "I am so tired." This would support Stress Overload. Defensive Coping would be not appropriate as he can state stressors in his life. He does not express Hopelessness in his statement to the nurse. The nurse needs more data, such as difficulty falling asleep and interrupted sleep, to support Disturbed Sleep Pattern.
You might also like to view...
The patient is ready to be discharged from the hospital. When should discharge planning begin?
A) The day prior to discharge B) The day of estimated discharge C) The day the patient is admitted D) Once the nurse determines care needs
The parent of a 3-year-old child tells the nurse, "My daughter points instead of speaking whenever she wants me to get something for her, but she understands me when I ask her to do something." Based on the parent's comment, what does the nurse suspect?
a. Age-appropriate language development b. An expressive language delay c. A receptive language delay d. A potential hearing deficit
The patient who is receiving antipsychotic medication complains of having a dry mouth. The patient refused the morning dose of the medication. What is the best response by the nurse?
1. "Why are you refusing the medicine?" 2. "I can give you benztropine (Cogentin) for your dry mouth." 3. "I will let your doctor know about your dry mouth." 4. "A dry mouth is common, but drinking more water will help."
Typically, the nurse manager of a unit uses a participatory style of leadership. Today, a patient suffered a cardiac arrest. The manager took over the patient's care, issuing orders, and expecting staff to obey them immediately
Which type of leadership did this manager exhibit today? Select all that apply. 1. Bureaucratic 2. Autocratic 3. Permissive 4. Directive 5. Authoritarian