The school nurse recognizes that an adolescent comes from a family with limited financial resources. The nurse is developing a nursing care plan to assist the adolescent with his needs. An appropriate nursing diagnosis would be:
1. Altered financial support related to inadequate parental support.
2. Imbalanced nutrition: Less than body requirements related to familial financial difficulties.
3. Knowledge deficit related to sources of financial support.
4. Risk for injury related to imbalanced nutrition.
2
Rationale 1: Nurses have limited ability to intervene in areas related to finance. This is not a legitimate nursing diagnosis.
Rationale 2: Imbalanced nutrition is a nursing diagnosis and is appropriate.
Rationale 3: Referral to community resources may be necessary, but the diagnosis of imbalance nutrition is more appropriate and comprehensive.
Rationale 4: This is two diagnoses in one. A clearer diagnosis is simply imbalanced nutrition.
Global Rationale:
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During the nurse's initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. The nurse should:
1. Administer the prescribed analgesic. 2. Ask the child's parents if they think the child is hurting. 3. Reassess the child in 15 minutes to see if the pain rating has changed. 4. Do nothing, since the child appears to be resting.
A male elder living in an adult community becomes a widower 1 month after retirement. Two months later, he has not resumed a weekly outing with his fishing club. Which should the nurse implement?
a. Ask the elder why he is not fishing. b. Have club members visit him at home. c. Meet with him to assess his interests. d. Enroll him in a weekly card game.
The nurse is concerned when which of the following occurs during the third stage of labor?
A) The amniotic sac remains attached to the placenta after the placenta is delivered. B) There is a sudden gush of bright red blood, and the uterus appears rounded C) The uterus continues to have contractions after the baby is delivered. D) The placenta has not delivered in the 30 minutes since the baby was delivered.
A client is being assessed for the possible presence of inflammation and infection. The nurse would consider a white blood cell count greater than ______ mm3 as evidence that inflammation exists
Fill in the blank with the appropriate word.