While performing an assessment of a patient who is immunocompromised, the nurse notes the child to have thrush in the mouth, tenderness over the spleen upon palpation, and a white blood cell count of 3,000
Which nursing diagnoses will the nurse include in the care plan of this child based on these findings? Select all that apply.
A) Ineffective protection
B) Risk for imbalanced nutrition, less than body requirements
C) Pain
D) Impaired skin integrity
E) Delayed growth and development
Ans: A, B, C
Based on these symptoms the diagnosis of Ineffective protection is related to the decreased white blood cell count; Risk for imbalanced nutrition, less than body requirements, is related to the thrush; and Pain is related to the tenderness over the spleen and the thrush. There is no evidence to support the diagnoses of Impaired skin integrity or Delayed growth and development.
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The nurse is aware that physiological changes associated with pain in the infant include which finding(s)?
a. Increased blood pressure and decreased arterial saturation b. Decreased blood pressure and increased arterial saturation c. Increased urine output and increased heart rate d. Decreased urine output and increased blood pressure
A 62-year-old teacher presents to the clinic for evaluation of the following symptoms: fever, headache, sinus congestion, sore throat, green nasal discharge, and cough. This cluster of symptoms is best explained by:
A) One disease process B) More than one disease process
With regard to sociocultural risk factors, nursing care should be based on the premise that:
a. risk for individual development of a psychiatric disorder usually remains constant over time. b. all members of ethnic groups have the same risk for developing a psychiatric disorder. c. risk factors interact constantly, so different factors become important at different times. d. sociocultural risk factors affect assessment and nursing care planning more than implementation of care.
Which of the following activities is a public health nurse most likely to be involved in during the twenty-first century?
a. Preventing the spread of communicable diseases b. Assisting uninsured clients in obtaining health care services c. Providing direct care services for uninsured individuals d. Developing multiagency collaborations and partnerships