Which nursing diagnosis is written in the correct format?
a. Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight
b. Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm
c. Impaired Swallowing related to absent gag reflex
d. Excess Fluid Volume related to 3 lb weight gain in 24 hours
ANS: C
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A nurse develops a plan of care for a family with nursing diagnosis of Caregiver Role Strain related to urinary incontinence. Which of the following interventions is the highest priority?
A) Administer diphenhydramine at bedtime. B) Assist the client to the bathroom prior to bedtime. C) Limit the fluid intake of the client to 1000 mL each day. D) Monitor bowels for diarrhea and constipation.
The nurse is administering heparin to a client who has had a cerebrovascular accident (CVA). Which of the following complications should the nurse monitor in this client?
A) Dyspnea B) Edema C) Nocturia D) Hemorrhage
What primarily determines the school health nurse's role in a community?
A. Community's priorities for its schools B. Local school system's goals as influenced by federal and state legislative dictates C. Nurse practice act of the state in which the nurse practices D. The employed nurse's education, credentials, and skill level
A patient diagnosed with psoriasis is being treated with topical corticosteroids. How should the nurse instruct the patient to apply the medication?
1. Apply the medication in a thin layer. 2. Avoid rubbing the medication into the skin. 3. Dry the skin thoroughly before applying the medication. 4. Continue the medication even if lesions worsen, because it is only a temporary reaction.