Which of the following are true related to nursing diagnoses? Select all that apply.
A. describe a disease or pathology of body systems
B. Describe human response to a health problem
C. Actual or potential physiologic complications related to disease or treatment.
D. Include descriptors and risk factors
E. Relates contributing factors or relationship to indentified health problem.
F. There are not associated legal ramifications
Answer:
B. Describe human response to a health problem
D. Include descriptors and risk factors
E. relates contributing factors or relationships to identified health problem
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The nurse is caring for a client who has a urostomy. Which of the following should the nurse use to maintain the client's peristomal skin?
A) Tampons B) Skin barrier products C) Antibiotic powder D) Skin tape
To evaluate a client's balance using Romberg's test, the nurse would
a. seat the client and request the client touch the nurse's outstretched finger with eyes closed. b. seat the client upright with eyes closed, and then ask the client to touch the nose. c. stand the client with feet a foot apart, eyes closed, and arms outstretched. d. stand the client with feet together, eyes closed, and arms to the side.
Fluid loss is most likely to be a problem for a patient with
a. a colostomy. b. a hiatal hernia. c. an ileostomy. d. Crohn's disease.
The student nurse is providing tracheostomy care to a patient who has intratracheal secretions and a damp tracheostomy dressing and ties. Which action by the student should the nursing instructor question?
a. Suctioning the tracheostomy tube before removing the soiled tracheostomy dressing b. Assisting the patient to semi-Fowler's position c. Placing new tracheostomy ties before cutting the old ties d. Cutting gauze pads to place around the tracheostomy tube