A patient hurriedly tells the community mental health nurse, "Everything's a disaster! I can't concentrate. My disability check didn't come. My roommate moved out, and I can't afford the rent. My therapist is moving away. I feel like I'm coming apart."
Which nursing diagnosis applies
a. Decisional conflict, related to challenges to personal values
b. Spiritual distress, related to ethical implications of treatment regimen
c. Anxiety, related to changes perceived as threatening to psychological equilibrium
d. Impaired environmental interpretation syndrome, related to solving multiple problems affecting security needs
?
ANS: C
Subjective and objective data obtained by the nurse suggest the patient is experiencing anxiety caused by multiple threats to security needs. Data are not present to suggest Decisional conflict, ethical conflicts around treatment causing Spiritual distress, or Impaired environmental interpretation syndrome.
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The perinatal nurse explains to the breast feeding class attendees that the epithelial lining of the ducts of the breast secrete the various components of breast milk into the lactiferous duct openings on the nipples
A) True B) False
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1. There is a history of regular menses every 28 days. 2. Amenorrhea is present and ovulation occurs with breastfeeding. 3. Oral contraception was discontinued, but no regular menstruation was established. 4. There has been one or months of amenorrhea. 5. There is an accurate date for the last menstrual period.
The nurse notes that a client's pupils are fixed and dilated. Which should the nurse suspect has occurred?
A. Damage to the pons. B. Glaucoma. C. Syphilis. D. Monocular blindness.