The nurse is caring for a patient with a history of hyperparathyroidism who presents with a serum calcium level of 14.5 mg/dL. What is the highest priority nursing diagnosis for this patient?
a. Risk for injury related to weakened bones that may easily fracture
b. Deficient knowledge related to need for supplemental calcium in diet
c. Risk for constipation caused by decreased gastrointestinal motility
d. Activity intolerance related to muscle cramping and spasms
ANS: A
Chronic hypercalcemia can lead to weakened bones as strengthening calcium is removed over time. Pathologic fractures can easily result, so risk for injury is a high priority nursing diagnosis for this patient. The other nursing diagnoses apply but are less important than the safety of the patient.
You might also like to view...
The nurse caring for a client diagnosed with cirrhosis of the liver promotes a diet:
1. High in protein and carbohydrates. 2. High in vitamin B and fats. 3. High in fat and vitamin K, low in protein. 4. Low in protein, with vitamin K and B supplements.
A community member returns home after having spinal fusion surgery for spinal stenosis. What recommendation should the population health nurse make to help with this client's health restoration?
1. Focusing on weight management activities. 2. Participating in rehabilitation to promote maximum physical functioning. 3. Encouraging to have needed vaccinations during the next care provider visit. 4. Requesting prescriptions from the care provider to ensure adequate pain management.
The nurse is working with a client who is in denial. Before attempting to break down the client's defense mechanisms and cope with the stressor, the nurse should determine that the client is able to:
1. speak clearly and articulately. 2. use one or more alternative ways of coping. 3. financially afford long-term psychological services, such as counseling. 4. correctly identify that denial is actually being used.
A faith community nurse is partnering with a local public health department to develop programs for primary, secondary, and tertiary prevention activities. Which of the following should be used as the primary guide for development?
a. Contemporary articles in nursing journals b. Evidence-based practice guidelines for treatment of disease c. Healthy People 2020 goals and objectives d. Preferences of partners who are funding the programs