Which nursing diagnosis applies to the client post heart transplant and the need to learn about the signs and symptom of organ rejection?
a. Fear c. Risk for Infection
b. Deficient Knowledge d. Ineffective Breathing
B
Deficient Knowledge related to home care following transplantation is the appropriate diagnosis. The client will discuss signs and symptoms of rejection. The client will demonstrate an understanding of the side effects of immunosuppressive drugs and lifestyle changes to adapt to their effects. Teach client and family about signs of rejection and infection as well as the ramifications of taking immunosuppressive medications. Teach client to watch for side effects and report them to physician.
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A client being treated for compartment syndrome has been hospitalized for 4 days. He has no history
of psychiatric disorder but is described by his family as being "a difficult person who finds fault with others.". From the day of admission he has verbally abused the nurses for their inability to provide care that keeps him pain free and comfortable. The most likely explanation lies in a. poor child-rearing that did not teach respect for others. b. automatic thinking leading to cognitive distortion. c. a personality style that externalizes problems. d. delusions that others wish to harm him.
What should the initial action of a nurse be when providing first aid to a person with spontaneous epistaxis?
a. Apply direct pressure for 3 to 5 minutes. b. Have the person sit down and lean for-ward. c. Have the person lie down and apply an ice pack. d. Have the person clear the nasal passages by blowing the nose.
The nurse is going to assess a client according to a nursing assessment model. The model that the nurse would most likely NOT use would be:
a. functional health patterns. c. Roy adaptation model b. theory of self-care. d. body systems model.
The nursing action that has the highest priority for a 32-year-old client with an implanted radiation source should focus on
a. assessing the client's reaction to the diagnosis and treatment. b. preventing skin problems related to radiation. c. promoting regular activity while confined to the room. d. safeguarding the client and others from unnecessary radiation exposure.