The nurse is caring for an oncology patient who is vomiting. When writing a plan of care for this patient, what would be an appropriate nursing diagnosis?
A) Risk for injury related to cardiovascular effects
B) Deficient knowledge regarding motion sickness
C) Decreased cardiac output related to cardiac effects
D) Acute pain related to constipation
C
Feedback:
Nursing diagnoses related to drug therapy might include decreased cardiac output related to cardiac effects. Answers A, B, and D are not appropriate nursing diagnoses for this patient.
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Which is considered the main relay station for sensory information related to pain?
1. Cerebral cortex 2. Limbic system 3. Thalamus 4. Reticular system
After a nurse addresses an agitated client by setting limits in a calm, direct manner, the client begins pacing, exhibiting a clenched jaw and fists. The nurse would evaluate the approach as ineffective because:
1. The nurse lacks rapport with the client. 2. The nurse lacks adequate de-escalation and limit setting skills. 3. Some clients have limited control, so verbal interventions may not work, but this is not reflective of the nurse's skill. 4. In some cases verbal de-escalation and limit setting will not work and the nurse should start with a more restrictive measure.
A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include?
a. Dilating the stoma b. Assessing bowel function c. Limitation of physical activities d. Measures to prevent prolapse of the rectum
Which cerebrospinal fluid analysis result will be most important for the nurse to communicate to the health care provider?
a. Specific gravity 1.007 b. Protein 65 mg/dL (0.65 g/L) c. Glucose 45 mg/dL (1.7 mmol/L) d. White blood cell (WBC) count 4 cells/?L