The nurse knows that which nursing diagnoses are most important when considering care of a patient with anorexia nervosa? Select all that apply
1. Anxiety
2. Powerlessness
3. Body Image, Disturbed
4. Self-Esteem, Chronic Low
5. Nutrition, Imbalanced: Less Than Body Requirements
Answer: 3, 5
Explanation: While all the answer choices represent possible nursing diagnoses for patients with eating disorders, at the core of most eating disorder pathology is the over evaluation of the importance of body shape and the control of body weight. Therefore, the primary nursing diagnoses patients with eating disorders will be either disturbed body image or, for those patients whose priority is weight restoration, imbalanced nutrition: less than body requirements.
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The nurse is documenting information about the client using Problem-Oriented Charting and the acronym SOAP. Rank the following pieces of information in the order that they should be documented
Standard Text: Click and drag the options below to move them up or down. 1. The client's skin is cool and dusky. Poor capillary refill noted. Oxygen saturation level is 90% on room air. The client was diagnosed with COPD in 1993. 2. The nurse will apply oxygen at 2 liters per minute, per healthcare provider's orders when the client's oxygen saturation level is below 92%. 3. The client states, "I am so tired all of the time. I feel like I'm not getting enough air into my lungs.". 4. The client is most likely experiencing an exacerbation of a chronic lung disease.
In planning care for a preschool-age child, the nurse knows that which open body postures encourage positive communication? Select all that apply
a. Leaning away from the preschooler b. Frequent eye contact c. Hands on hips d. Conversing at eye level e. Asking the parents to stay in the room
After abdominoplasty, the nurse would place the client in the
a. low-Fowler position. b. mid-Fowler position with knees bent. c. side-lying position. d. supine position with knees bent.
A patient reports to the emergency room nurse that she is 10 weeks pregnant, with unilateral pelvic pain, shoulder pain, and faintness. Her color is pale, she is diaphoretic, and her heart rate is 140 bpm. What is the nurse's priority action?
a. Initiate an ordered IV of lactated Ringer's at 200 mL/hr. b. Take the patient for her ordered pelvic ultrasound. c. Ask the patient if she has had any recent vaginal bleeding. d. Ask the patient if she has ever been told she has had salpingitis.