While the nurse is changing the female client's dressing, the client states she is not ready to see the wound. Which does the nurse implement to promote client health and well-being?
1. Documents that the client has ineffective coping
2. Shields the wound from the client's line of vision
3. Takes a photograph of wound for client to see later
4. Tells the client to see the injury as soon as possible
2
2. The client exhibits self-awareness by telling the nurse she is not ready to see the wound, so the nurse obstructs the client's view of the wound during wound care and the dressing change. After the dressing change, the nurse, without judgment or coer-cion, takes time to explore the client's reluctance to view the wound.
1. The client effectively copes with the wound by telling the nurse she is not ready to view it. The client potentially feels pain during the wound care or does not deal with wounds of any sort and thus copes with her wound by handling one aspect of the wound at a time.
3. The nurse asks permission from the client before recording the wound with a pho-tograph because it can violate the client's right to privacy.
4. The client has the right to participate in her own care, so telling the client to look at the wound can be interpreted as coercion or an attempt to use guilt to convince the client to look at the wound.
You might also like to view...
At what level should a nurse attach a secondary administration set (piggyback) medication bag to a primary bag of IV solution?
a. at the same level b. below the level c. above the level d. It makes no difference as long as the piggyback drips without problem.
What activity is carried out during the implementing step of the nursing process?
A) Assessments are made to identify human responses to health problems. B) Mutual goals are established and desired client outcomes are determined. C) Planned nursing actions (interventions) are carried out. D) Desired outcomes are evaluated and, if necessary, the plan is modified.
After a head injury, what is it called when air enters into the cerebrospinal fluid (CSF)–filled spaces within the head?
a. Pneumocephalus c. Battle's sign b. Hemotympanum d. Raccoon sign
The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis?
1. Increased hematocrit 2. Decreased BUN 3. Increased blood sugar 4. Increased sedimentation rate