A client with relapsing-remitting multiple sclerosis tells the nurse that even though the primary symptoms of exacerbation are leg spasms and blurred vision, the hardest part is trying to get through the day because of being so tired
Which diagnosis should the nurse identify as a priority for this client?
A) Fatigue
B) Disturbed Sensory Perception
C) Impaired Physical Mobility
D) Self-Care Deficit
Answer: A
The client states that the worst part of the disease exacerbation is being tired even though leg spasms and blurred vision are present. The nurse should identify the diagnosis of Fatigue as being a priority for this client. The diagnoses of Impaired Physical Mobility because of the leg spasms and Disturbed Sensory Perception because of the blurred vision are additional nursing diagnoses applicable for this client, but they are not the priority based on the client's statement. The client may or may not have a Self-Care Deficit.
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A nurse on a busy medical unit provides care for many patients who require indwelling urinary catheters at some point during their hospital care
The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which patient? A) A patient whose diagnosis of chronic kidney disease requires a fluid restriction B) A patient who has Alzheimer's disease and who is acutely agitated C) A patient who is on bed rest following a recent episode of venous thromboembolism D) A patient who has decreased mobility following a transmetatarsal amputation
The nurse recognizes the activity that reflects primary prevention is
a. a self-initiated walking regimen. b. collaboration with a physical therapist. c. physician-prescribed exercise after a heart attack. d. tuberculosis screening.
The family member caring for a dependent older patient tells the nurse that she feels his care is "so out of my control." To best assist the caregiver in achieving a sense of confidence, the nurse
a. encourages the caregiver to regularly at-tend the meeting of a local support group. b. identifies the skills and resources that the caregiver needs to provide for the patient. c. arranges for in-home support services to assist with care as needed. d. explores reasons why the caregiver feels such a lack of control.
The best way to reduce the risk of asphyxiation (choking) in toddlers is to make sure that they
a. drink plenty of fluids with meals. b. avoid conversation during meals. c. sit down while eating and chew foods well. d. eat using utensils rather than with their fingers.