The nurse assisting with prioritizing nursing diagnoses would select which of the following as the highest priority?
1. Impaired adjustment
2. Acute pain
3. Risk for imbalanced body temperature
4. Ineffective airway clearance
4
Without a clear airway, there is no need for the other diagnoses.
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A nurse is working with a woman who is newly married and pregnant and says she is distressed because she and her husband seem to be so different and they argue over petty issues. What action by the nurse using group theory would be best?
A. Ask the woman if she can remember why she and her husband fell in love. B. Caution her that this level of disagreement will cause stress to the unborn baby. C. Offer the woman a referral to a community counseling center for couples therapy. D. Reassure her that this is normal and help her brainstorm ways to work cooperatively.
An RN working the 11 to 7 shift on Saturday night receives the following phone call from a recently discharged client, "I'm breastfeeding and my nipples are getting very sore. My baby is nursing every 4 hours for about 10 minutes on each side
Do you have any suggestions for me?" What is the best response to this inquiry? a. "Feed from only one breast each feeding to allow each side time to heal." b. "It may help to nurse your baby more fre-quently and alternate positions." c. "Remove a nipple from one of the sample bottles you received and use it to protect your nipple while you nurse." d. "Try giving your baby formula for a day until your nipples heal."
Male patients require ______________________ before and during androgen therapy
1. A digital prostate exam 2. A Doppler exam of testicular blood flow 3. Urine analysis for proteinuria 4. Serial orthostatic blood pressures
Which finding is expected when assessing a child hospitalized for asthma?
a. Inspiratory stridor b. Harsh, barky cough c. Wheezing d. Rhinorrhea