Which of the following would the nurse most likely identify as a nursing diagnosis for a client who is receiving an immunization?
A) Risk for Infection
B) Acute Pain
C) Hyperthermia
D) Ineffective Coping
Ans: B
Feedback:
The client who is receiving an immunization would most likely experience pain at the injection site; therefore, Acute Pain would be most appropriate. If the drug was not given, then the client would be at risk for infection. Although fever may occur, Hyperthermia as a nursing diagnosis would be inappropriate. Ineffective Coping would not be associated with immunologic agents.
You might also like to view...
Which of the following is an early warning sign of hypertrophic pyloric stenosis?
a. the infant looking and acting somewhat sick b. the infant being hungry and wanting to feed again very soon after vomiting c. milk running out of the infant's mouth periodically during the feeding d. unusually loud burping sounds
The nurse assesses for diminished or absence sensation, numbness, and tingling on a child who has had a cast applied to treat a fracture. For what is the nurse monitoring?
A) Pain B) Pallor C) Paresthesia D) Paralysis
Problems that lack clarity and cannot be solved by leader expertise or normal ways of doing things in the organization are technical challenges
a. True b. False
A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse provides instruction regarding foods to avoid. Which menu choice by the client indicates to the nurse that the client needs further instruction?
A. Fish B. Spinach C. Rhubarb D. American cheese