Which nursing diagnoses would be applicable for a client who is experiencing a situational crisis? Select all that apply
A) Ineffective Coping
B) Risk for Self-Directed Violence
C) Spiritual Distress
D) Risk for Loneliness
Answer: A, B, C
Loneliness may result from an individual's actions following a crisis, but it is not an appropriate nursing diagnosis for situational crisis. The other three answers are among the most common nursing diagnoses for people in crisis.
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A patient is admitted to the unit and the nurse assesses whether he or she is at increased risk for infection when what factors are determined? (Select all that apply.)
A) Malnutrition B) Hypertension C) Suppression of immune system D) Advanced age E) Decreased amylase levels
A client is scheduled for a hypophysectomy for the management of a pituitary tumor. What are the nurse's priorities in caring for this client? Select all that apply
A) Assure the client that he will make it through the surgery without any difficulty. B) Help the client cope with changes in physical appearance. C) Pace activities to accommodate the client's fatigue. D) Relieve discomfort from headaches, abdominal distention, and skeletal pain. E) Instruct the client on how to cough and deep breath postoperatively.
The nurse receives a report on an infant whose analysis indicates 47 total chromosomes, with the abnormality noted at chromosome 21. What additional assessments will the nurse include when evaluating the infant?
a. Cleft palate b. Protruding tongue c. Extra fingers or toes (polydactyly) d. Intellectual developmental delay
An older adult patient is severely suicidal. The patient has not eaten for a week and today began refusing fluids. The patient's physical condition is declining. The nurse should prepare for which intervention?
a. Insertion of a feeding tube b. Electroconvulsive therapy (ECT) c. Behavior modification d. Bright-light therapy