A nurse is preparing a care plan for a child with autistic disorder. Which of the following would be an appropriate nursing diagnosis for this client?
A) Hopelessness related to separation from parents
B) Disturbed Sensory Perception related to diminished awareness of stimuli
C) Disturbed Sleep Pattern related to excessive hyperactivity
D) Risk for Other-Directed Violence related to a history of aggressive acts
Ans: B
An appropriate nursing diagnosis for a child with autistic disorder would include Disturbed Sensory Perception. Hopelessness may be related to conduct disorder. Disturbed Sleep Pattern would be appropriate for clients with ADHD. Risk for Other-Directed Violence correlates with conduct disorder.
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A client who is post percutaneous transluminal coronary angioplasty (PTCA) reports severe chest pain. Which action does the nurse take first?
a. Administer the prescribed IV morphine. b. Administer the prescribed sublingual ni-troglycerin. c. Assess the client's vital signs and notify the health care provider. d. Perform an immediate 12-lead ECG.
The nurse wants to transfer the client to the chair and the client receives an antihypertensive medication. Which clinical indicator from the client cues the nurse to increase preventive meas-ures for client injury during a transfer?
1. Hypokalemia 2. Facial redness 3. Sinus tachycardia 4. Mild peripheral edema
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Indicate whether the statement is true or false.