The nurse is assisting in the care of a patient with ankylosing spondylitis. What should the nurse expect to find in the patient's collaborative plan of care? (Select all that apply.)
a. Physical therapy daily
b. Sitz baths three times daily
c. Tylenol #3 every 4 hours prn pain
d. Administer Remicade as prescribed
e. Activity as tolerated; up with assistance
ANS: A, C, D, E
Nursing care focuses on patient education and administration and evaluation of prescribed medications. Pain management, rest periods, and assistance with activities of daily living (ADLs) are provided. B. Sitz baths are not indicated for this health problem.
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A young mother asks the nurse in a pediatric office for information about safety, diet, and immunizations for her baby. Which nursing diagnosis would be appropriate for this patient?
A) Knowledge Deficit: Infant care C) Readiness for Enhanced Parenting B) Impaired Health Maintenance D) Readiness for Enhanced Coping
A nurse leads a "Healthy Aging" class at a community health center. Which question should the nurse use to generate discussion among participants in this setting?
A) "How did you adjust to your move from your house to the assisted living facility Irma?" B) "Are you satisfied with the care that you're getting from your family doctor, Elizabeth?" C) "Donald, could you tell us why your grandson is living with you?" D) "Have you had any tests done on your heart since we last met, Marie?"
The nurse is caring for a client who is diagnosed with glaucoma. The client wants to know why this condition can lead to blindness. What is the best response by the nurse?
1. The fluid in the eye blocks the optic nerve. 2. Pressure around the optic nerve builds over time. 3. The optic nerve cannot transmit signals with glaucoma. 4. The optic nerve atrophies.
The nurse is caring for a patient with chronic liver failure. Which medication order should the nurse question?
a. Lactulose b. Neomycin c. Multivitamins d. Acetaminophen