Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder?
A. Altered thought processes R/T increased stress
B. Risk for suicide R/T loneliness
C. Risk for violence: directed toward others R/T paranoid thinking
D. Social isolation R/T inability to relate to others
D
An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are unsociable.
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The nurse is collecting data for a patient who has a bulging eardrum. The nurse recognizes that this indicates which of the following?
a. Otitis media b. Hematoma in the middle ear c. External ear infection d. Normal tympanic membrane
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%
What do these signs and symptoms indicate for this client? A) The development of chronic obstructive pulmonary disease (COPD) B) The development of left-sided heart failure C) The development of right-sided heart failure D) The development of cor pulmonale
A patient undergoing spinal surgery is receiving low-dose intravenous lidocaine prior to surgery. The patient reports being lightheaded and having numbness in his tongue. What nursing action is indicated?
1. Increase the rate of the lidocaine drip. 2. Give a 250-mL normal saline bolus intravenously. 3. Discontinue the lidocaine drip. 4. Start intravenous lipids at an infusion frat of 1.5 mL/kg/min.
The nurse is reviewing a client's recent labwork conducted during a recent annual physical. The nurse notices an elevated serum creatinine. What does this mean clinically?
a. This is a normal lab value. b. The kidneys are failing to excrete waste products. c. The client may have bladder cancer. d. The client was dehydrated at the time of the labwork.