During a routine prenatal visit, the nurse finds an increase in the blood pressure of a client who is 24 weeks pregnant. The nurse would identify which of the following nursing diagnoses as being appropriate for the client at this time?
1. Excess Fluid Volume
2. Risk for Deficient Fluid Volume
3. Ineffective Coping
4. Anxiety
2. Risk for Deficient Fluid Volume
Rationale:
The rise in blood pressure could be a precursor to a fluid shift from intravascular to extravascular spaces seen in preeclampsia. The client would be at risk for fluid volume deficit. Not enough information is provided to determine if the client is experiencing fluid volume overload. There is no information to support ineffective coping or anxiety in the client.
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A child has been diagnosed with sickle-cell disease. Both parents deny having the disease themselves. The parents ask the nurse how their child got this disease. The nurse recognizes that the only possible explanation of the etiology is:
1. The father is not the biological father of the infant. 2. The mother of the child has the trait, but the father doesn't. 3. The father of the child has the trait, but the mother doesn't. 4. The mother and the father of the child have the sickle-cell trait.
In order to identify the latest research about the nursing care of diabetes, a nursing student has consulted a nursing publication that comes out four times a year and that contains the most up-to-date nursing knowledge
What information resource has this student utilized? A) Textbook B) Journal C) Brochure D) Website
The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis
To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output
A patient who is being treated for a deep vein thrombosis (DVT) complains of chest pain and shortness of breath. What should the nurse do first?
A. Measure the patient's blood pressure. B. Assess the pulses on the extremity with the thrombosis. C. Assess the extremity with the thrombosis. D. Elevate the head of the bed and begin oxygen therapy.