A nurse is developing a plan of care for a client receiving anticonvulsant therapy and identifies a nursing diagnosis of Risk for Injury. Which assessment findings would support this nursing diagnosis? Select all that apply
A) Epistaxis
B) Reports of blurred vision
C) Complaints of dizziness
D) Photosensitivity
E) Scaling red rash
Ans: B, C, D
Feedback:
A client would be at risk for injury if the client was experiencing blurred vision, dizziness, and photosensitivity. Epistaxis would support a nursing diagnosis of a possible Risk for Injury related to a reduction in platelets from hematologic adverse reactions. A scaling red rash would support a nursing diagnosis of Impaired Skin Integrity.
You might also like to view...
What are the leading causes of death in older adults?
a. Vehicular accidents and suicide b. Cardiovascular disease and diabetes mel-litus c. Alcoholism and cirrhosis d. Cancer and strokes
The family of a woman being treated with intracavitary radiation for endometrial cancer asks why the client is in a private room. What is the nurse's best response?
A. "She needs quiet to recover from the fatigue associated with radiation therapy." B. "She is less likely to become depressed if she doesn't have to tell a roommate that she has cancer." C. "She has some radiation inside her for a few days, and a private room prevents radiation exposure to others." D. "She will become sick and lose her hair with this treatment, so it is best that she is not disturbed by others."
When teaching a patient newly diagnosed with type 2 diabetes who is prescribed to take miglitol (Glyset) as antidiabetic therapy, which instruction is most important?
a. "Rotate the injection site on a weekly basis." b. "Take this drug with the first bite of your meal." c. "Do not mix this drug in the same syringe as insulin." d. "Be sure to take this drug at the usual time even if your meal is delayed."
Prepare a 0.4 mg dose from a supply of 2 mg per mL. Express your answer to the nearest tenth
What will be an ideal response?