Your client, who has acute vertebral compression fractures, complains of severe pain when moved. The client's heart rate is 120 and weak, and the blood pressure is 180/90. What nursing diagnosis would be most appropriate?
1. Impaired physical mobility
2. Acute pain
3. Activity intolerance
4. Risk for injury
ANS: 2
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A parent asks the nurse about immunizing her 7-month-old daughter against the flu. Which response by the nurse would be most appropriate?
A) "She really doesn't need the vaccine until she reaches 1 year of age.". B) "She will probably receive it the next time she is to get her routine shots.". C) "Since your daughter is older than 6 months, she should get the vaccine every year.". D) "The vaccine has many side effects, so she wouldn't get it until she's ready to go to school.".
A nurse is working with an individual who has a low literacy level. Which of the following barri-ers to learning should the nurse anticipate?
a. Asking for additional clarification of ma-terials b. Requesting to read the information later c. Having a high level of anxiety d. Being overly dependent on others
A 20-year-old male presents to his physician complaining of difficulty breathing when lying down. This condition is referred to as:
A. dyspnea on exertion. B. orthopnea. C. apnea. D. tachypnea.
A nurse refers to a flow chart to select an appropriate dressing for a client. For an open, shallow wound with a moderate amount of drainage, the nurse:
A. Applies transparent film B. Uses gel-impregnated gauze C. Selects an alginate wound pouch D. Leaves the wound open to air to drain