An expected outcome for a client with a nursing diagnosis of ineffective coping related to inef-fective problem solving is that the client will:
1. Decide if he wants dessert
2. Develop positive self-esteem
3. Identify pros and cons of getting own apartment
4. Recognize the positive qualities of the psychiatrist
ANS: 3
An outcome statement derives from the nursing diagnosis and is a projection of the expected in-fluence that nursing interventions will have on the client. It provides specific, measurable indica-tors by which to evaluate the results of nursing interventions. Option 3 is the only statement that refers to ineffective problem solving.
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A client with severe metabolic alkalosis is admitted to the unit. Which is the priority for the client?
A) Administering medication for metabolic alkalosis B) Monitoring oxygen saturation C) Teaching the client the risk factors for metabolic alkalosis D) Setting goals for the client with metabolic alkalosis
A nurse is assessing the hearing acuity of a client using audiometric hearing tests. The decibel range at which the client can hear is recorded as 78 dB. What is the hearing level of the client?
A) Moderately impaired B) Moderately to severely impaired C) Severely impaired D) Profoundly impaired
The nurse is providing instruction regarding nitroglycerin for angina to the client who will be discharged. The nurse should explain that the medication should be taken at the first indication of pain because:
1. Pain will cause tissue damage. 2. Pain indicates decreased blood flow to the heart. 3. Pain in the legs could indicate overactivity. 4. Nitroglycerin constricts blood vessels and increases blood pressure.
During an assessment of a patient's cranial nerves, the nurse states, "Please stick out your tongue." The nurse observes that the tongue deviates markedly to the right side. What is the patient most likely exhibiting?
1. abnormal hypoglossal nerve response 2. first cranial nerve (CN I) damage 3. sluggish oculomotor response 4. absence of the Homans sign