The nurse is planning care for a child with a diagnosis of pyloric stenosis during the preoperative phase. Which goal has the highest priority at this time?
A) Preparing family for home care
B) Promoting comfort
C) Maintaining skin integrity
D) Improving hydration
Ans: D
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Which of the following is the correct sequence of steps in making a nursing diagnosis?
1. Generate hypotheses about possible nursing diagnoses, check for defining characteristics, cluster assessment data into meaningful sets, choose the appropriate diagnostic label, and determine the etiology. 2. Compare cue clusters with assessment data, generate differential diagnoses, determine the etiology, make the diagnosis, plan interventions, and write the "related to" statement. 3. Review the assessment data, cluster the data into meaningful sets, compare clusters with defining characteristics of possible diagnoses, choose the appropriate nursing diagnosis, determine the etiology, and write the "related to" statement. 4. Cluster data into meaningful sets, choose the appropriate nursing diagnosis, compare diagnosis with assessment data, determine the etiology, plan interventions, and write the "related to" statement.
During unit staff meetings, you observe that Marg rolls her eyes and snorts whenever Julia makes a comment. Your first response as a unit manager is to:
a. Discuss what you have observed with Marg. b. File immediate documentation in Marg's personnel file. c. Ask Julie to monitor Marg's behavior during meetings. d. Ignore the behavior, as Marg is one of your strongest nurses.
The nurse educator is teaching a group of students about the different cultural rituals that are associated with grief and loss. Which statement by a student indicates correct understanding of the information presented?
1) "A patient of Muslim descent may want to have his or her body washed two times after death by a person of the same sex." 2) "A patient of Chinese descent may request Santero near the time of death." 3) "A patient of Arab descent may request that candles are lit in the room after death to light the path to the afterlife." 4) "A patient of Korean descent may want rice wine sprinkled on the grave."
The nurse is working on an orthopedic unit in the local hospital
While assessing her patient the patient states, "Ever since we had the earthquake in California I can't sleep for fear of another one happening during the night, and I just keep having flashbacks of the earthquake." The nurse knows that these patient statements are most consistent with: a. Anxiety b. Lack of coping skills c. Post-traumatic stress disorder d. Crisis