A patient hospitalized after an MI is restlessly moving about in bed. Her pulse, blood pressure, and respiratory rate are elevated. In a shaky voice, she tells the nurse, "I think I am going to die. The pain is gone, but it could come back anytime
Where is the doctor? Why isn't the doctor here with me?" The nurse should analyze this behavior as suggesting the nursing diagnosis of: a. Spiritual distress.
b. Ineffective breathing pattern.
c. Nonadherence.
d. Anxiety.
D
The clinical picture is typical of anxiety. The patient is experiencing uneasy feelings arising from her insecurity about her health. Anxiety typically produces elevated vital signs. Data do not support the other nursing diagnoses.
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A patient is admitted with heat exposure exhaustion and has a body temperature of 107°F. The patient has flushed dry skin and is not sweating. What portion of the skin or skin appendages has this situation interfered with the function of?
A) Apocrine sweat glands B) Hypodermis C) Epidermis D) Eccrine sweat glands
A client is prescribed albuterol for bronchospasm in chronic bronchial asthma. Which of the following nursing diagnoses would the nurse expect to see on the care plan as a result of the adverse reaction of albuterol?
A) Anxiety B) Risk of Impaired Oral Mucous Membranes C) Ineffective Tissue Perfusion D) Risk of Injury
A client who has been taking an anxiolytic comes to the clinic with the following signs and symptoms: nausea and vomiting, headache, anxiety, irritability, muscle tremors, and insomnia. The nurse should consider that the client may be experiencing:
a. drug overdose. c. an idiosyncratic reaction to the drug. b. sudden drug withdrawal. d. a hypersensitivity reaction to the drug.
A young woman comes in with brief, rapid, jerky, irregular movements. They can occur at rest or during other intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements?
A) Tics B) Dystonia C) Athetosis D) Chorea