The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?
A) Risk for impaired skin integrity due to cast and location
B) Deficient knowledge related to cast care
C) Risk for delayed development related to immobility
D) Self-care deficit related to immobility
Ans: A
Although deficient knowledge, risk for delayed development, and self-care deficit may be applicable, the child is at increased risk for skin breakdown due to the size of the cast and its location. In addition, the cast has an opening, which allows for elimination. Soiling of cast edges or leakage of urine or stool can lead to skin breakdown.
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A patient comes into the clinic complaining of a runny nose and facial pain. The nurse's initial assessment would include:
1. assessment for nasal drainage and sinus tenderness. 2. transillumination and nasal speculum examination. 3. palpation of the frontal and maxillary sinuses and tonsillar inspection. 4. turbinate assessment and assessment for patency of the nares.
A nurse is preparing a patient for an invasive diagnostic procedure of the urinary system. What statement by the nurse would help reduce the patient's anxiety?
A) "We do these procedures every day, so you don't need to worry." B) "I have had this done to me, and it only hurt for a little while." C) "Why are you so worried? Do you think you have a tumor?" D) "Let me explain to you what they do during this procedure."
Which of the following is the most appropriate nursing intervention for a patient with schizophrenia?
A) Teach the patient about the illness B) Maintain consistency with the patient's plan of care C) Insist that the patient participate in all activities provided on the unit D) Allow the patient time to listen to the radio alone in his or her room
There is an outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in the community
The nurse is responsible for the dissemination of the education plan adopted by the public health department. Key components of the plan should include: (Select all that apply.) A) Quarantining infected families in their homes B) Respiratory hygiene C) Hand hygiene D) Droplet precautions for visitors in contact with affected clients E) Contact precautions for all cases