During an assessment, the nurse notes that a client receiving radiation treatments for breast cancer has excoriated skin. What is the priority nursing diagnosis for this client?
A) Excess Fluid Volume
B) Ineffective Breathing Pattern
C) Risk for Infection
D) Activity Intolerance
Answer: C
Radiation causes skin excoriation. With the excoriation, the client is at risk for infection due to skin breakdown. The client who receives radiation is more at risk for fluid volume deficit. Depending on the assessment, the client may or may not have activity intolerance. There is no evidence of respiratory difficulties in this client.
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Acts whose performance is required, permitted, or prohibited are defined by ___________ of ______________
ANS:
A hospice nurse is critically evaluating various models of grief used for terminally ill clients and their families. Which should the nurse recognize when applying these models to individual client cases?
A) No clear timetables exist, nor are there clear-cut stages of grief. B) There is strong research proving that these models are not useful for many dying clients. C) The models serve as clear and definitive predictors of grief behaviors. D) The Kübler-Ross model is primarily used to describe anticipatory grief.
The spouse of a patient with Alzheimer's disease (AD) asks, "Can you give me a simple explanation of what happened in my partner's brain?" Select the nurse's best response
a. "Dementia developed." b. "The brain became overstimulated with chemical messages." c. "Brain cells and chemical messengers that form memories are dying." d. "The substantia nigra, a tissue that makes dopamine, has degenerated."
The nurse is planning care for a patient with type 1 diabetes mellitus. Which action should the nurse identify as being the most effective to reduce the development of complications?
A. Performance of effective foot care B. Knowing symptoms of urinary tract infections C. Self-monitoring of blood glucose levels D. The necessity of a yearly eye examination