Mrs. Yamada has been admitted to the psychiatric unit because of her worsening diagnosis of major depression that has not responded appreciably to treatment. In light of Mrs. Yamada's statement that "everything would be better if I was just dead and gone,
the nurse would be justified in identifying what type of nursing diagnosis related to suicide?
A) Risk nursing diagnosis
B) Wellness nursing diagnosis
C) Actual nursing diagnosis
D) Syndrome nursing diagnosis
Ans: A
This client's psychiatric diagnosis coupled with her statement that refers to suicide would justify a risk nursing diagnosis of "risk for suicide related to depression."
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A nurse is assessing a patient for a perineal hematoma. Which action by the nurse is most appropriate?
A. Assist the woman to a knee-chest position with head down. B. Have the patient lie supine and place her legs in frog-leg position. C. Place the patient in a side-lying position and lift the upper buttock. D. Turn the woman side to side and lift the upper leg each time.
The nurse is assessing the ears, nose and mouth of an Asian client with a student nurse. Which of the following statements made by the nurse to the student nurse about cultural differences is accurate?
1. "Asians are more likely to experience greater difficulty with otitis media than people from other cultures. " 2. "Sometimes in Asians and Native Americans, their ear wax looks dry and dark.". 3. "Asians have a higher risk of having issues associated with cleft lips and cleft palates.". 4. "Asians have a high incidence of tooth decay.".
The nurse is concerned that a patient, being mechanically ventilated, is at risk for developing barotrauma. The type of cycling mechanism that the ventilator is providing would be
1. pressure. 2. time. 3. flow. 4. volume.
The third stage of the grieving process is
A) shock. B) bargaining. C) anger. D) depression.