A psychiatric nurse can make a nursing diagnosis and address it in the nursing care plan as a nursing concern when which of the following criteria are met?
a. The nursing diagnosis is probable or potential, but not yet substantiated by either objective or subjective assessment data.
b. The nursing diagnosis must be substantiated by objective assessment data.
c. The nursing diagnosis is substantiated by either objective or subjective assessment data.
d. The client does not have to agree that it is an area of nursing concern nor desire nursing treatment for it.
C
A nursing diagnosis must be substantiated by either objective or subjective assessment data to become a component of the nursing care plan. The assessed data and nursing diagnosis will then be used by the nurse to determine expected outcomes and a plan for interventions.
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Which comment made by a school-age child indicates that he needs more teaching about diabetes mellitus and exercise?
a. "I carry a piece of hard candy with me in case I start to feel shaky." b. "I make sure I have emergency money when I have soccer practice or a game." c. "Sometimes I skip my breakfast when I have a game in the morning." d. "I play in soccer games that are scheduled after dinner."
A client with end-stage cirrhosis and gastrointestinal bleeding becomes combative and confused. What complication of cirrhosis may this client be experiencing?
A. Ascites B. Coagulation defects C. Transient ischemic attack D. Portal-systemic encephalopathy
The nurse is working with a child with severe burns who is not eating much. What strategy will the nurse most likely use to get the child to eat more?
a. Explain how eating more helps a person get well quicker. b. Offer rewards for eating more. c. Serve food more often. d. Have other children or family members eat with this child.
In partnership with the community, what is the last step in planning a community-based health program?
A) List the sequence of actions and prepare a time schedule for achieving goals B) Identify resources needed to accomplish the plan. C) Outline revisions to the plan as goals and objectives are achieved or changed D) Record the plan in a concise, standardized, and retrievable form