In planning care for a patient with a C4 spinal cord injury admitted to the intensive care unit, the nurse would document which of the following nursing diagnoses as a priority for this patient?
A) Risk for impaired skin integrity related to immobility and sensory loss
B) Impaired physical mobility related to loss of motor function
C) Ineffective breathing patterns related to weakness of the intercostal muscles
D) Urinary retention related to inability to void spontaneously
Ans: C
Feedback: A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury requires ventilatory support because the diaphragm and intercostals are affected.
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An elderly patient with osteoarthritis has been told that he cannot have a joint replaced at this time. The patient is having progressive difficulty with normal self-care activities
Which of the following is this patient at risk for developing? 1. dehydration 2. depression 3. delirium 4. dementia
You are assisting a patient obtain a clean-voided urine specimen. The patient accidentally puts tissue in the collection container. What do you do?
What will be an ideal response?
A client who is an attorney says to the clinic nurse, "I'm worried about my wife. She's been so distant and disorganized since our son died of leukemia 4 months ago. She never suggests that we go out or take our other children anywhere. Is this normal, or do I need to get her to a doctor?" Which statement by the nurse would be therapeutic?
A. "Absolutely. It sounds as if she may be experiencing a severe depression." B. "To be safe, it would not hurt to have her see your family doctor, or maybe you have a member of the clergy she can talk to." C. "The reluctance to resume activities and overprotect your other children is a normal part of bereavement and will subside in 2 months." D. "It's normal, but by the end of a year you can expect that your wife is improving and able to redirect her energy. Have you expressed your concerns to her?"
In a patient with ____________________ paralysis, the extremities move in an involuntary pattern, similar to muscle spasms.
Fill in the blank(s) with the appropriate word(s).