The white blood cell count (WBC) of a client with systemic lupus erythematousus (SLE) shows a shift to the left. Which of the following is a priority nursing diagnosis for this client?
1. Ineffective Health Maintenance
2. Impaired Skin Integrity
3. Ineffective Coping
4. Ineffective Protection
4. Ineffective Protection
Rationale:
All identified diagnoses are appropriate for a client with SLE. However, the results of the laboratory test demonstrates an increased risk for infection. A shift to the left in a WBC differential indicates an increased number of immature cells, suggesting infection, and is therefore the priority for the nurse.
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A 75-year-old patient is tearful, shaky, and withdrawn. She tells you that she is "worrying herself to death" about losing her aging husband and being "all alone." You recognize this reaction as Anxiety rather than Fear because (choose all that apply):
1) it concerns future or anticipated events. 2) it concerns anticipation of danger rather than a present danger. 3) there is no shakiness or tearfulness present. 4) there is a psychological rather than a physical threat.
The nurse knows that the caregiver of a patient with a respiratory illness understands discharge teaching when the caregiver makes which statement?
1. "I can expect to hear adventitious sounds only in the mornings; the rest of the day, breath sounds should be normal." 2. "If I hear extra sounds during a deep breath, I know I am hearing adventitious sounds." 3. "Adventitious sounds may be heard during inspiration or expiration because of secretions or inflammation." 4. "I will know I am hearing adventitious breath sounds if I hear any sounds when I listen over the lower chest."
In histrionic personality disorder, the primary aim of the essential features and symptomatic behaviors is to:
a. keep the person as the focus of attention b. maintain rigid, ritualistic order c. foster a sense of grandiose entitlement d. bully others into submission
The nurse is providing teaching to a client who has just been diagnosed with breast cancer. How would the nurse describe a malignant tumor?
Standard Text: Select all that apply. 1. Slow growing 2. Invasive 3. Lethal if left untreated 4. May be classified as a carcinoma 5. May be classified as a sarcoma