While assessing a client, the nurse observes hives and flushing. The client reports itching and a tightness in the throat. The nurse would identify which of the following nursing diagnoses?
A) Risk for Allergy Response
B) Ineffective Tissue Perfusion
C) Decreased Cardiac Output
D) Risk for Injury
Ans: A
Feedback:
The client is exhibiting signs and symptoms of an allergic reaction. Therefore, Risk for Allergy Response would be appropriate. Ineffective Tissue Perfusion and Decreased Cardiac Output would be appropriate if a client is experiencing hypotension and shock. Risk for Injury would be appropriate if the client was experiencing dizziness, weakness, confusion, or disorientation related to the drug therapy.
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You are evaluating the plan of care for an older adult who is alcohol-dependent. Which patient documentation indicates the need for follow-up nursing interventions by the nurse?
a. Patient states that he intends to decrease his alcohol consumption. b. Patient arrives at his group session on time and well-groomed. c. Patient states, "I am an alcoholic because I drink 10 beers a day." d. Patient states that he understands that he needs continued treatment.
As a new nurse manager, which are effective ways to increase your power levels on the unit? Select all that apply
1. Do favors for those working on the unit. 2. Be consistent. 3. Defend the staff at all times. 4. Keep your word and follow through. 5. Fix problems immediately. 6. Follow the chain of command.
A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours
When the nurse reports to the ED physician, which client symptom should be the nurse's first priority? 1. Hearing and visual impairment 2. Blood pressure of 180/100 mm Hg 3. Mood rating of 2/10 on numeric scale 4. Dehydration
When inspecting the ear of a 2-year-old child with suspected otitis media, you should do all of the following, EXCEPT
a. ask the child where it hurts. b. pull the lower auricle down and out to straighten the canal. c. insert the speculum about 1/4 inch to 1/2 inch. d. introduce air into the canal by gently squeezing the bulb attachment.