In caring for a patient with a uterine rupture, the nurse determines which nursing diagnoses to be appropriate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Risk for Impaired Gas Exchange
2. Fear related to unknown
3. Impaired Individual Coping
4. Impaired Physical Mobility
5. Anxiety
1,2,3,5
Rationale 1: This diagnosis could apply to both mother and fetus.
Rationale 2: The patient would experience fear related to an unknown outcome.
Rationale 3: Impaired coping would result from the emergent situation secondary to uterine rupture.
Rationale 4: There should be no impaired mobility.
Rationale 5: There will be anxiety related to emergency procedures and unknown fetal outcome.
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A nurse educator is a teaching a group of students about the comprehensive theory of addiction by George Engel. Which statements indicate that the students understand the theory? Select all that apply
A) "Addiction occurs due to a lack of emotional attachment." B) "There is a biological factor involved in the development of addiction." C) "There are social factors that contribute to the development of addiction." D) "There is a moral factor involved in the development of addiction." E) "There is a psychological factor involved in the development of addiction."
The nurse is caring for a 13-year-old female client diagnosed with urethritis. Which of the following assessment answers would indicate that further instruction is needed? Select all that apply
A) "I change my sanitary napkin when it is full." B) "My mom buys just regular toilet paper." C) "I take a bubble bath a couple of times per week." D) "I clean my private area with soap and water." E) "I drink fruit drinks because I do not like water."
Which client is at highest risk for the development of plantar fasciitis?
a. Young adult runner b. Adolescent swimmer c. Older adult client who walks with a cane d. Adult client confined to a wheelchair
The nurse is planning care for a client who just received 25 mcg of misoprostol (Cytotec) vaginally to ripen the cervix. Which interventions should the nurse plan to implement? (Select all that apply.)
a. Assist the client to the bathroom. b. Position the client in a high Fowler position. c. Assess the uterus for excessive contractions. d. Monitor the fetal heart rate for at least 30 minutes.