Your client is a 76-year-old man with a history of diabetes mellitus, type II. He is having more difficulty managing his diabetes, is losing weight, and has an unkempt appearance. Your nursing diagnosis should be:
1. Knowledge deficit.
2. Imbalanced nutrition: less than body requirements.
3. Ineffective therapeutic regimen.
4. Ineffective health maintenance.
ANS: 4
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The patient has been diagnosed with severe aortic valve stenosis. Considering the most common symptoms caused by aortic valve stenosis, what is the most important nursing intervention?
A) Document characteristics of the aortic stenosis murmur. B) Teach patient to rise slowly from a supine position. C) Assess peripheral circulation more frequently. D) Assess for and document pulmonary adventitious sounds.
When assessing the breasts, it is important for the patient to lift the arms over the head. Why?
A) Adds tension to suspensory ligaments B) Eventuates dimpling and retraction C) De-emphasizes suspensory ligament retraction D) Accentuates signs of unilateral nipple inversion
A public health nursing instructor educates a class that the Predisposing, Reinforcing and Enabling factors, and Causes in Educational Diagnosis and Evaluation (PRECEDE) component of the PRECEDE-PROCEED begins with
A. An examination of administrative and organizational issues B. A comprehensive community assessment C. Preventative programs D. The implementation of behavior change
A nursing student visits a healthcare facility and asks the infection control nurse about
the reasons the nurses are at risk in the healthcare facility. Which factor places the nurse at highest risk for contracting an infection? A) Repeated contact with infectious materials and clients. B) Taking care of clients with infections. C) Administering medications to the client. D) Working with staff in various departments.