The nurse is developing the postoperative plan of care for a patient recovering from surgery for oral cancer. Which nursing diagnosis has the highest priority?
1. Ineffective Airway Clearance
2. Impaired Verbal Communication
3. Body Image Disturbance
4. Risk for Imbalanced Nutrition: More than Body Requirements
1
Rationale 1: Ineffective Airway Clearance is appropriate for this patient and has the highest priority.
Rationale 2: Impaired Verbal Communication is an appropriate nursing diagnosis for this patient, but it is not of the highest priority.
Rationale 3: Depending on the extent of the resection, Body Image Disturbance may be an appropriate nursing diagnosis, but it does not hold the highest priority.
Rationale 4: The nutrition nursing diagnosis is more likely to be Risk for Imbalanced Nutrition: Less than Body Requirements.
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Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct?
a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.
A resident is dying. When communicating with the person, which is correct?
a. Speak loudly. b. Assume that the person can no longer hear if he does not provide a response to you. c. Ask open-ended questions which lead into a conversation. d. Offer words of comfort.
The client is going to be started on cholestyramine (Questran), 6 mg, three times daily. What instruction should the nurse provide to this client?
1. Take with large amounts of fluid. 2. Take in the morning. 3. Take with food. 4. Take without food.
The nurse is caring for a patient with acute pancreatitis demonstrating signs of hypovolemic shock. Which interventions will be included in this patient's plan of care?
1. Administer high doses of potassium. 2. Monitor pulmonary arterial wedge pressure. 3. Administer several liters of intravenous fluids in the first few hours of treatment. 4. Administer anticholinergic medication. 5. Monitor central venous pressure.