During the admission process, the nurse obtains information about a patient through the physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?
a. Deficient fluid volume
b. Impaired gas exchange
c. Risk for injury: Seizures
d. Risk for impaired skin integrity
ANS: C
The patient's muscle cramps and low serum calcium level indicate that the patient is at risk for seizures and/or tetany. The other diagnoses are not supported by the data because the skin turgor is good. The lungs are clear, arterial blood gases are normal, and there is no evidence of edema or dehydration that might suggest that the patient is at risk for impaired skin integrity.
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A child has been diagnosed with sickle-cell disease. The parents ask the nurse how their child got this disease. Which of the following is the best response to give the parents?
1. The mother and the father of the child have the sickle-cell trait. 2. The mother of the child has the trait, but the father doesn't. 3. The father of the child has the trait, but the mother doesn't. 4. The mother of the child has sickle-cell disease, but the father doesn't have the disease or the trait.
The daughter of an older patient is concerned that the patient continues to drive at age 81. What should the nurse share with the daughter and patient about motor vehicle accidents and older people?
1. The elderly have few wrecks, as they are more cautious drivers. 2. There are few studies available looking at this particular concern. 3. The risks of seniors over age 80 are similar to those of teen drivers. 4. Accidents are the result of cognitive changes not related to sensory problems.
Which of the following techniques from the era of primitive man utilized a form of massage to heal?
A) Twisting B) Starving C) Purging D) Pummeling
During a postpartum assessment, the nurse suspects a vaginal or cervical laceration. This conclusion is based on which assessment(s)? (Select all that apply.)
a. Bright red vaginal bleeding b. Firmly contracted uterus c. Perineal pain d. Dark red vaginal bleeding e. Pulse rate of 100 beats/minute