A diabetic client is to have a mid-thigh amputation of his left leg. He tells the nurse "I guess I will be
called 'Gimpy' after the surgery. My life is really going to change when I cannot carry out my
exercise program any more.".
The nurse assesses that the client is at risk for the nursing diagnosis of
a. spiritual distress.
b. ineffective denial.
c. disturbed body image.
d. impaired social interaction.
C
The nature of the surgery, which involves an actual change in body structure, places the client at
greater risk for developing disturbed body image than any of the other diagnoses listed. The client's
statements about what he is expecting also suggest risk for this diagnosis.
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After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition?
a. "I must decrease my intake of fat." b. "I will increase my intake of protein." c. "A decreased intake of carbohydrates will be required." d. "An increased intake of vitamin C is necessary."
A nurse working in the intensive care unit (ICU) is caring for a client in progressive hemorrhagic shock. When planning care for this client, which does the nurse anticipate?
A) A sustained decrease of 10mmHg of the client's mean arterial pressure (MAP) B) A blood loss of 25% C) A change from aerobic to anaerobic metabolism D) A decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space
A civilian patient admitted with frostbite burns to her feet is receiving pain medication and fluid replacement and is being monitored for any signs of organ dysfunction. What rationale would the nurse provide for this conservative management?
1. Frostbite injuries are not as serious as thermal or chemical burns. 2. The extent of the injury is not obvious. 3. Little is known about other methods to treat frostbite. 4. Aggressive frostbite management is only done in specialty military hospitals.
When the nurse truly empowers the client, positive outcomes can be the result. Which of the following prerequisites to empowerment include persons who have the freedom to be very true, authentic selves?
A) Power by purpose B) Power by reflection C) Power by gestault D) Power by giving