The nurse has admitted a child with a ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?
1. Hypothermia related to decreased metabolic state
2. Acute pain related to the effects of a congenital heart defect
3. Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect
4. Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow
4
Rationale 1: Ventricular septal defects do not cause pain, fever, or deficient fluid volume.
Rationale 2: Ventricular septal defects do not cause pain, fever, or deficient fluid volume.
Rationale 3: VSDs are left to right shunts, which increases pulmonary blood flow without cyanosis.
Rationale 4: Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis.
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The nurse caring for a client diagnosed with rheumatoid arthritis assesses the client's pain frequently and notes that the client reports less pain during family visits. The nurse attributes this to which of the following?
1. The client's pain isn't as bad as he says it is if he is okay during visits. 2. The client is ashamed to have family members know he is in pain. 3. Cumulative effects of pain medications sustain the client through the visit. 4. Support systems help people handle pain more easily.
Which of the following is true about the relationship between reliability and validity?
a. As reliability increases, validity decreases. b. If a measure is reliable, it will be valid. c. There is no relationship between these two concepts. d. Unless a measure is reliable, it cannot be valid.
The nurse is collecting data from a client. Which of the following best reflects objective data?
A) Religion B) Occupation C) Appearance D) Age
The nurse is caring for a client diagnosed with a terminal illness and experiencing a great deal of pain. After administration of IV analgesia, the client continues to complain of severe pain. Which action by the nurse is the most appropriate in this situation?
1. Explain to the client the need to wait for further medication to prevent overdosage complications. 2. Ask the family to help divert the client from the discomfort. 3. Call the health care provider, if necessary, to request an order for additional analgesia. 4. Wait an hour for the medication to take effect.