The patient is perspiring, has an increase in pulse and blood pressure, and states, "I am so worried about this operation, I can't think straight." What is the most appropriate nursing diagnosis for this patient?
a. Ineffective Individual Coping c. Powerlessness
b. Anxiety d. Impaired Adjustment
B
Anxiety is manifested by changes in vital signs and increased sweating. The patient might also verbalize feelings of helplessness, lost of control, nervousness, and fear. Ineffective Individual Coping is manifested by the inability to meet basic needs and the inability to ask for help. Powerlessness is manifested by passive giving-up behavior. Impaired Adjustment is the inability to reach homeostasis.
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The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the:
a. Nucleus pulposus. b. Articular processes. c. Medial epicondyle. d. Glenohumeral joint.
A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent?
1. The client is paranoid. 2. The client is 87 years old. 3. The client incorrectly reports his or her spouse's name, date, and time of day. 4. The client relies on his or her spouse to interpret the information.
The patient exclaims, "I am sorry I am late for my appointment, but I ran into so much traffic on the way here." She is out of breath and her face is red. Her vital signs are: P 100, R 30, BP 150/90, and T 98°F
What is the most appropriate action? A) Document vital signs. B) Disregard vital signs and retake in 5 minutes. C) Retake vital signs in 5 minutes. D) Document vital signs and retake in 5 minutes.
The nurse is conducting a physical assessment for a homeless patient. Which action by the nurse is most appropriate?
1) Donning full personal protective equipment (PPE) before touching the patient 2) Asking the patient the last time personal hygiene was performed 3) Gaining permission from the patient before touching 4) Telling the patient to remove clothing and place in a bag