When prioritizing a client's problems, the nurse is aware that clients at risk for alterations in self-concept require:
a. a referral to social services
b. frequent monitoring against self-harm
c. a complete health history and physical assessment
d. development of a healthy self-concept
C
Clients at risk for alterations in self-concept, identity, body image, self-esteem, and role performance require a health history and physical examination.
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In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make?
a. "Does your family know you are drinking every day?" b. "Does the tremor change when you drink alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."
A nurse has just received the shift handoff report. Which patient should the nurse assess first?
A. A patient who has rheumatoid arthritis and is having an endoscopy this morning B. A patient who has asthma and had difficulty breathing during the night C. A postoperative cholecystectomy patient who has a drain and needs discharge teaching D. A patient who has sickle cell anemia reporting pain and received pain medication 10 minutes ago
The nurse is caring for a 4-year-old girl with vulvovaginitis. The nurse is explaining to the girl's mother how to help prevent subsequent episodes. Which of the following responses indicates a need for further teaching?
A) "She needs to wipe from front to back." B) "I will ensure she changes her underwear every day." C) "She should probably avoid bubble baths." D) "I will help supervise her wiping after bowel movements."
The healthcare team is working to prevent the development of multiple organ dysfunction syndrome (MODS) in a critically injured patient. The nurse would evaluate that these efforts have failed when which findings develop?
1. Systemic inflammatory response syndrome (SIRS) is confirmed. 2. Transfusion is required. 3. Laboratory findings over the last 24 hours indicated renal failure. 4. Respiratory distress and gastrointestinal bleeding have persisted for 36 hours.