The nurse observes a balloon-shaped outpouching on the abdomen of a cardiac patient in the CCU. The nurse recognizes this as which of the following?
A) Fusiform aneurysm
B) False aneurysm
C) Saccular aneurysm
D) Thoracic aneurysm
C
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When conducting a nursing assessment of the gastrointestinal tract, all of the following questions may be helpful except
a. Food intolerances b. Use of laxatives c. Sexual activity d. Abdominal distress before or after meals
A client's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest
the client may be hallucinating include a. aloofness, haughtiness, and suspicion. b. elevated mood, hyperactivity, and distractibility. c. performing rituals and avoiding open places. d. darting eyes, tilted head, and mumbling to self.
When a nurse is developing a no-suicide contract with a client, which of these aspects MUST be considered?
a. To increase client accountability, ask the client to promise the nurse or another significant friend or family member to avoid self-harm. b. To communicate belief in the client, establish a minimum time frame of at least 1 week for the first contract. c. To make the agreement more official and binding, have the document typed, signed by the client, and notarized. d. To decrease impulsive behavior, include a detailed plan of action with the names and phone numbers of persons to call and the number of the local suicide crisis hotline to call if experiencing suicidal thoughts.
Your client, who has acute vertebral compression fractures, complains of severe pain when moved. The client's heart rate is 120 and weak, and the blood pressure is 180/90. What nursing diagnosis would be most appropriate?
1. Impaired physical mobility 2. Acute pain 3. Activity intolerance 4. Risk for injury