A client diagnosed with oral cancer has undergone surgery to manage the condition, resulting in scarring both inside and outside of the oral cavity
The nurse developing the plan of care identifies which of the following nursing diagnoses as having highest priority? 1. Nutrition, Imbalanced: more than body requirements, risk for
2. Body Image, Disturbed
3. Communication: impaired, verbal
4. Knowledge Deficient regarding causative factor of disease process
Nutrition, Imbalanced: more than body requirements, risk for
Rationale: While each of the nursing diagnoses listed is appropriate for the client, nutrition has the highest priority because it affects wound healing and general health. Deferring to Maslow's hierarchy, the physiological diagnoses would have the highest priority.
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The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated during labor. The nurse knows the client education was successful when the client states, "During labor, the nurse will:
1. "Check my cervix by doing a pelvic exam every two hours.". 2. "Assess the baby's heart rate with an electronic fetal monitor.". 3. "Look at the color and amount of bloody show that I have.". 4. "Verify that my contractions are strong but not too close together.".
The nurse is assessing a young adult and determines that the individual has achieved successful resolution of the previous stage of growth and development, evidenced by demonstrating which of the following?
A) Drive and hope B) Direction and purpose C) Devotion and fidelity D) Production and care
The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan?
A. enemas are given to empty the bowel after the procedure B. the xray procedure may last for several hours C. a nasogastric tube (NGT) is inserted to instill the barium D. nothing by mouth is allowed for 6 to 8 hours before the study
A pt has late-stage chronic glomerulonephritis. which educational bronchus would be the most appropriate to prepare for the pt?
a. how to take your antiinfective medication b. important points to know about dialysis c. what are the side effects of radiation therapy? d. precautions to take during immunosuppressive therapy