Mrs. Lopez has a severe visual impairment and has been hospitalized twice for falls occurring at home. Which of the following might be an appropriate nursing diagnosis for her?
a. Ineffective health maintenance related to knowledge deficit
b. Ineffective health maintenance related to safety hazards
c. Potential risk for further development
d. Potential risk for infection
B
You might also like to view...
The nurse caring for a Navajo client notes a lack of verbal communication when attempting to interact with the client. Which inference can be made about this behavior?
1. The client likely does not understand the nurse's attempts to engage her. 2. The client is demonstrating disapproval with the nurse through the use of silence. 3. The client is uneasy speaking with the nurse without the male head of her household. 4. The client is illustrating agreement with the nurse's actions by using silence.
A client with amyotrophic lateral sclerosis is becoming increasingly debilitated. Recently, he told
the nurse "It bothers me that I cannot get to church anymore. Since I have not been able to get to services, I feel out of touch with God. I pray but I wonder if my prayers are heard.". The nurse should consider the nursing diagnosis of a. powerlessness. b. death anxiety. c. spiritual distress. d. disturbed thought processes.
To test for Homans' sign, the nurse would:
1. dorsiflex the client's foot while the knee is flexed at 90 degrees. 2. plantarflex the client's foot while the hip is slightly flexed. 3. plantarflex the client's foot while the knee is extended. 4. dorsiflex the client's foot while the knee is slightly bent.
A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing:
A. Venous insufficiency B. Intermittent claudication C. Sore muscles from overexertion D. Muscle cramps related to musculoskeletal problems