The nurse is caring for a 65-year-old mother of three who recently underwent abdominal surgery and has a colostomy as a result
The patient has a history of multiple surgeries, including a tracheostomy after lung surgery about 20 years earlier that has since healed over. To determine how to best work with this patient, the nurse should do which of the following? a. Determine how the patient dealt with her previous surgeries.
b. Realize that past coping mechanisms are always positive in nature.
c. Approach care in a standard method because all patients are the same.
d. Avoid using family input in determining the course of care.
A
Your nursing assessment includes consideration of previous coping behaviors. Knowing how a patient has dealt with self-concept stressors in the past provides insight into the patient's style of coping. Not all patients address issues in the same way, but often a person uses a familiar coping pattern for newly encountered stressors. As you identify previous coping patterns, it is useful to determine whether these patterns have contributed to healthy functioning or created more problems. Exploring resources and strengths, such as availability of significant others or prior use of community resources, is important when formulating a realistic and effective plan.
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Ana is admitted to the medical surgical floor for severe weight loss. Her diagnosis is anorexia nervosa. She is 16 and looks about 8. Her daily intake is about eight cans of diet soda. Your initial nursing goal is:
A. Establish trust. B. Request nutritional supplements from Dietary. C. Explore with her the rationale for refusing to eat. D. B and C
An LVN/LPN is evaluating the response of a patient 30 minutes after receiving an antihypertensive medication administered by the RN team leader. The LPN/LVN assesses the patient's blood pressure and notes the patient is now hypotensive
What is this is an example of? a. An adverse effect b. A desired response to a medication c. A therapeutic effect d. An allergic reaction
A client is admitted with third-degree burns of the upper arms and chest. When assessing the client, the nurse should expect the skin to appear as:
1. white with patches of blackened skin. 2. bluish-purple with blisters. 3. diffusely bright red and swollen. 4. reddened and covered with blisters.
A patient is demonstrating signs of a delayed immunological response to a virus. Which component of the immune system is responsible for beginning this response?
1. Complement 2. Intact functioning T cells 3. Functioning human leukocyte antigens 4. Intact functioning B cells