A young adult with a severe episode of asthma bronchoconstriction comes to the emergency department with signs of respiratory distress
When the nurse performs the admission assessment, she notes that the patient is not able to say where she is or the time. Which nursing diagnosis is probably most suitable for this patient?
a. Chronic Confusion
b. Acute Confusion
c. Impaired Verbal Communication
d. Readiness for Enhanced Communication
B
This patient is experiencing Acute Confusion caused by lack of oxygen related to her respiratory distress. As a young adult with an acute episode of asthma, this patient would not likely have a history of confusion; therefore, without more data, Chronic Confusion is not an appropriate diagnosis for this patient. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia, but not with confusion. Readiness for Enhanced Communication is appropriate when the patient expresses willingness to enhance communication.
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A patient has researched a medical condition on the Internet. The nurse's best response to the patient's questions and concerns is
a. "Have you verified this information with your doctor?" b. "Quality health information is not available on the web." c. "What websites did you visit to get this information?" d. "You can't really trust what you find on the Internet."
A client, who was recently being laid off from work, is scheduled for a biopsy to detect a malignancy. When planning this client's care, which does the nurse include?
A) Reasons to delay the biopsy B) Medicate around the clock for pain C) Interventions to address anxiety D) Social services to aid with financial planning
It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently use her time and provide this education?
a. Write down instructions so the patient can read them at home. b. Discuss the information while assisting the patient with his bath. c. Educate the patient about his medications as each one is given. d. Follow up with the patient after discharge with a phone call.
The nurse knows that parents need further teaching with regard to the treatment of congenital clubfoot when they state what?
a. "We'll keep the cast dry." b. "We're happy this is the only cast our baby will need." c. "We'll watch for any swelling of the foot while the cast is on." d. "We're getting a special car seat to accommodate the cast."