When reviewing the nursing plan of care for a client with a multi-year diagnosis of multiple myeloma, the nurse finds which of the following nursing diagnoses most consistent with this condition?
1. Ineffective Breathing Pattern
2. Injury, risk for
3. Disturbed Body Image
4. Imbalanced Body Temperature, risk for
2
Rationale: The client with multiple myeloma is at high risk for bone fractures due to the increasing brittleness of bone tissue, so risk for injury would be the priority diagnosis for this client.
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Hydrocephalus is suspected in a 4-month-old infant. Which of the following would the nurse expect to assess?
A) Sunken fontanels B) Diminished reflexes C) Lower extremity spasticity D) Skull symmetry
A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct?
a. Obtain a fetal heart rate. b. Determine the estimated due date. c. Auscultate anterior and posterior breath sounds. d. Ask the client when she last had something to eat.
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication?
a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood
A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
a. Risk for injury: Check on patient every 15 minutes. b. Risk for suffocation: Place "Oxygen in Use" sign on door. c. Disturbed body image: Encourage patient to express concerns about body. d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.