The nursing diagnosis established for the client in chronic renal failure (CRF) is related to significant osteodystrophy. Which of the following does the nurse set as the priority nursing diagnosis for this client?
1. Risk for Injury
2. Risk for Bleeding
3. Disturbed Body Image
4. Anxiety
1. Risk for Injury
Rationale:
The client in CRF with significant osteodystrophy (osteoporosis, or calcium loss from the bones) is at high risk for fractures; therefore, preventing injury is the most appropriate outcome. The client is at risk for anemia, but not bleeding. The client on hemodialysis may have a disturbed body image, but in this case, it is specified that the client has significant osteodystrophy. Anxiety is not related to osteodystrophy.
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The nurse auscultates the fetal heart rate and determines a rate of 152 . Which nursing intervention is appropriate?
a. Inform the mother that the rate is normal. b. Reassess the fetal heart rate in 5 minutes because the rate is too high. c. Report the fetal heart rate to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast.
A patient asks the surgical nurse why the anesthesiologist asked if a member of his family ever had hyperthermia during surgery. The nurse responds that malignant hyperthermia is a life-threatening crisis that:
A) is transmitted in an autosomal recessive pattern. B) is transmitted in an autosomal dominant pattern. C) is an X-linked trait. D) is caused by an extra chromosome.
When a clean-voided specimen is ordered, the nurse should instruct the patient to
a. clean the area as directed and collect the initial urine voided b. clean the area as directed, start to void into the toilet, collect the urine in the sterile cup after a good flow of urine has been established c. clean the area as directed and collect all the urine voided d. clean the area as directed, start to void, and collect three samples at different times during the voiding
The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.)
A) X B) VIII C) VII D) IX E) XII