Which of the following nursing diagnoses would the nurse incorporate in the plan of care of a newly diagnosed client with polycystic disease? Select all that apply
1. Alteration in Comfort
2. Ineffective Coping
3. Risk for Impaired Mobility
4. Impaired Skin Integrity
5. Impaired Gas Exchange
Correct
1. Alteration in Comfort
2. Ineffective Coping
3. Risk for Impaired Mobility
Rationale: Alteration in comfort. The client with polycystic disease will experience abdominal and lumbar pain. Ineffective coping. Half of children born to a client with polycystic disease will have the disease, which is also progressive. Risk for impaired mobility. The pain of polycystic disease may decrease the client's ability to ambulate. Impaired skin integrity. The skin is not affected with this disease. Impaired gas exchange. The respiratory system is not involved with a newly diagnosed client.
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What important personal safety issues can the nurse alert older adults and their families to?(Select all that apply) Standard Text: Select all that apply
1. Keep bank books and credit cards in a secure place 2. Maintain an active cell phone 3. Program emergency contacts into home and cell phones 4. Do a home safety inspection 5. Provide referrals for at home services
Bertha is 81 years old and was admitted to hospital after contracting community-acquired pneumonia. She had been bedridden for 3 days, so her nurse arranged for a physiotherapist to assist her out of bed to help her slowly regain her mobility
Bertha decided not to wait for the physiotherapist, and after arising in the morning, she eased herself out of the bed and stood up. Suddenly Bertha's vision dimmed and she felt light-headed and dizzy. A passing nurse saw her fall back to the bed and rushed to help her. The nurse comforted Bertha, and then suspecting orthostatic hypotension, went to find a sphygmomanometer to check her blood pressure. Prolonged bed rest decreases plasma levels and vasomotor tone, which can both lead to orthostatic hypotension. How do changes in vascular resistance and radius affect blood flow? Assuming Bertha is otherwise healthy, how does her heart activity change in an attempt to compensate for the orthostatic hypotension she experienced? Considering the venous circulation, how is blood from the lower extremities returned to the heart? Why did Bertha's capillary fluid pressure (or hydrostatic pressure) change when she moved from a lying to standing position?
When a nurse is pushing or pulling a client, which of these positions should the nurse assume?
a. Stand near the client with both feet firmly planted. b. Stand near the client, and place one foot partially ahead of the other. c. Lean into the client, and move the client with a swift motion. d. Lean away from the client, and apply maximum pressure.
The nurse assesses the client's water-seal drainage (WSD) system connected to two chest tubes. Which is an unexpected finding for a properly functioning WSD system?
1. Fluid drains into the WSD collection chamber slowly. 2. Serosanguinous chest tube drainage postoperatively. 3. Fluid in water-seal chamber fluctuates with breathing. 4. Tape covers WSD system vent and not the connections.