The mental health nurse is developing a plan of care for a victim of sexual assault. Which nursing diagnoses are likely appropriate for this client? (Select all that apply.)
A) Anxiety
B) Impaired verbal communication
C) Noncompliance
D) Risk for injury
E) Deficient knowledge
Ans: A, B, D
Nursing diagnoses related to care of the client who has experienced a sexual assault would include anxiety, impaired verbal communication, and risk for injury.
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When instructing a patient on techniques to follow while performing a breast self-examination, the nurse instructs the patient to:
A) Use 1 or 2 fingers to examine the breast. B) Perform the entire examination while standing in front of the mirror. C) Place a pillow or folded towel under the shoulder of the breast you are not examining. D) Palpate the breast in the shower while they are soapy and possible changes are easy to detect.
Which of the following theorists coined the term "basic nursing care"?
A. Wiedenbach B. Henderson C. Hall D. None of the above.
A patient has blindness related to a functional neurological (conversion) disorder. To help the patient eat, the nurse should:
a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed him- or herself after explaining the arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self unassisted. d. address the needs of other patients in the dining room, and then feed this patient.
The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions. Which of the following data would support this diagnosis?
1. Skin is dry, cracked 2. One large with several smaller open, ulcerated areas on right leg 3. Client does not drive 4. Client states that does not use alcohol or drugs 5. Clothes are soiled 6. Client has obvious body odor