A 45-year-old female client who has a history of alcohol abuse develops severe jaundice and confusion; she also complains of nausea and indigestion
The client's blood pressure is elevated, both lower extremities are edematous, and the liver is enlarged. The client is admitted for treatment with a medical diagnosis of cirrhosis. What nursing diagnoses and interventions would be appropriate for this client?
The following are suggested guidelines for grading:
Potential Nursing Diagnoses Nursing Interventions
Excess fluid volume related to ascites Weigh client and measure abdominal girth daily; restrict fluid intake as ordered; monitor vital signs for evidence of development of portal hypertension and esophageal varices.
Risk for injury related to confusion Keep side rails raised; allow ambulation only with assistance; monitor for signs of hepatic coma.
Risk for impaired skin integrity related to edema Provide egg-crate mattress; monitor skin for signs of redness, breakdown, or evidence of petechiae; turn client every 2 hours; protect any areas subject to pressure.
Imbalanced nutrition, less than body requirements, related to inadequate diet Encourage client to eat; offer high-calorie meals with supplements as needed; provide frequent oral hygiene.
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A patient with a long-standing history of seasonal allergies has sought care during the spring and been advised to take a second-generation antihistamine
Which of the patient's following statements suggests a need for the nurse to perform health education? A) "I know these can be a bit expensive, but hopefully it will be worth it for me." B) "I'm really hoping that these pills will cure my allergies before summer starts." C) "I'll check with my doctor to make sure that the diet supplements I'm taking are okay to take at the same time as these pills." D) "It's handy that I don't necessarily have to take these pills at bedtime."
A client explains that meat is still an important component of the family meals and they can't figure out how to reduce the fat if they like meat so much. Which suggestion should the nurse make? (Select all that apply.)
a. Broil meat b. Avoid gravies c. Eat smaller portions d. Remove skin from poultry e. Reduce total calories per day
The patient complains of a metallic taste and loss of appetite. The nurse is concerned that the patient has developed
a. glycosuria. b. proteinuria. c. myoglobin. d. uremia.
Joshua recently moved into a dormitory to begin his freshman year in college
He was reprimanded by the dormitory supervisor for not properly disposing of food items and responded by throwing all of his belongings from a second story window while shouting obscenities. The campus police escorted him to campus health services, where he was diagnosed with an Adjustment Disorder with Disturbance of Conduct. Which of the following items in Joshua's history predispose him to this disorder? Select all that apply. A. Joshua reports that he doesn't have any friends in the dormitory. B. Joshua's family currently lives out of the country and are often difficult to reach. C. Joshua was notified the same day that he would have to withdraw from one of his classes because he didn't have the prerequisite credits needed to register for the class. D. Joshua has a higher than average GPA and is a member of The National Honor Society.