A nurse is developing a care plan for a newly admitted psychiatric client with paranoid schizophrenia. Which is an appropriate nursing diagnosis for this client?
A) Schizophrenia related to biochemical alterations
B) Self-care deficit (hygiene) related to altered reality orientation
C) Depressed mood related to multiple life stressors
D) Developmental disability related to early onset schizophrenia
B
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The nurse is teaching a female client about breast self-examination. How should the nurse describe a lesion that might be malignant?
1. The breast swells and is painful. 2. There is a sense of fullness prior to menses. 3. A small, hard lump that is painless is felt. 4. Most are found near the nipple.
A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of immunity does the nurse understand that the newborn will have?
A) Naturally acquired active immunity B) Artificially acquired active immunity C) Passive immunity transferred by the mother D) There is no immunity passed down from mother to child.
The nurse is taking care of a child who had a thyroidectomy. The nurse recognizes what as a positive Chvostek sign?
a. Paresthesia occurring in feet and toes b. Frequent sharp flexion of wrist and ankle joints c. Carpal spasm elicited by pressure applied to the nerves of the upper arm d. Facial muscle spasm elicited by tapping the facial nerve in the region of the parotid gland
Opinion leaders are:
a. formal leaders who lead evidence-based practice development teams. b. formal leaders who write new evi-dence-based practice guidelines. c. informal leaders who influence peers by evaluating innovations for use in certain settings and promoting clinicians' use of evidence in clinical decision making. d. informal leaders who gather data about nursing practice changes.