The nurse admits to the coronary care unit a patient diagnosed with an acute myocardial infarction. The patient's blood pressure reading is 86/38 secondary to an infusing nitroglycerine drip
Pulse rate is 120 beats/min and respirations are 14 breaths/min. The patient is pale and grimacing, and moans occasionally. What nursing diagnoses would the nurse anticipate for this patient? Select all that apply.
a. Acute Pain
b. Anxiety related to shortness of breath
c. Risk for shock
d. Decreased Cardiac Output
e. Decreased Cardiac Perfusion
ANS: A, C, E
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The events listed below occurred in the first few days of the nurse-client relationship. The
development of a positive relationship was hampered when the a. nurse had to cancel their second and third sessions because of short staffing. b. nurse let the client set the pace during the initial interview. c. client used the nurse as a sounding board while discussing recent work problems. d. nurse's initial impression was that the client would be interesting to work with.
Sometimes patients communicate by crying, moaning, or laughing. What should this behavior be considered?
a. Verbal communication b. Nonverbal communication c. Acting out and seeking attention d. Seeking holistic support
A nurse enters the patient's room and introduces himself stating, "Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and I will be with you until 3:30 PM
If you need anything, please call me on my phone or put your light on." He then gives the patient a printed card with this information. In the helping relationship, what does this represent? A) Intimate phase B) Orientation phase C) Working phase D) Termination phase
Mrs. Ballentine has been hospitalized for kidney disease and has been prescribed a low-sodium diet. When the nursing assistant brings in her lunch tray, Mrs. Ballentine says "Take that tasteless food away." What should the nursing assistant do?
A. Leave the food at her bedside, in case she gets hungry later in the day. B. Remove the food and report her refusal to the supervising nurse. C. Remove the food and say nothing; she has a right to refuse food. D. Insist that she eat six bites of her entree before taking the tray away.