During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed."
Based on these data, the best nursing diagnosis for the patient is
a. activity intolerance related to fatigue.
b. disturbed body image related to weight gain.
c. impaired skin integrity related to ankle edema.
d. impaired gas exchange related to dyspnea on exertion.
ANS: A
The patient's statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems.
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The nurse, working with a nursing student, is caring for a patient who is to receive interleukins. The student nurse asks you what happens physiologically when a patient receives interleukins. What is the nurse's best response?
A) "It really helps the patient!" B) "The patient has increases in the number of natural killer cells." C) "The patient has decreased cytokine activity." D) "The patient gets really sick from flu-like symptoms and then they get better."
In a busy rehabilitation unit, the team manager decided that the best way to reward the staff was to give them a monetary bonus rather than time off
The staff was very concerned about the decision and went to the administration with a number of complaints. Critical thinking is a process that entails a number of steps. What steps did the manager omit? She should have (select all that apply): a. Identified what assumptions were underpinning the issues. b. Considered why it was important to make this change or the context for the change. c. Considered how this change might affect staff relationships. d. Attained a majority consensus of all staff.
Which of the following is the best initial approach when a child has shown signs of regression?
a. Have the child sit in time-out and think about what he or she is doing and about his or her feelings. b. Ignore the regression, and compliment the child on positive attributes and behaviors. c. Ask the child why he or she is behaving like a little baby. d. Distract the child with new foods and new activities.
The nurse who is teaching a parent about developmental needs of the infant knows that the parent has verbalized understanding of a infant's developmental needs when he states
a. "My child is too young to understand words." b. "My child will begin to speak in sentences by 1 year of age." c. "My child will probably enjoy playing peek-a-boo." d. "While my child is in the hospital, I should let the nurses provide most of the care."