The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of Ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis?
A) Copes with sensory deprivation.
B) Registers normal body temperature.
C) Pays attention to grooming.
D) Obeys commands with appropriate motor responses.
Ans: D
Feedback: An expected outcome of the diagnosis of Ineffective tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of Disturbed sensory perception. The outcome of Registers normal body temperature relates to the diagnosis of Potential for ineffective thermoregulation. Body image disturbance would have a potential outcome of Pays attention to grooming.
You might also like to view...
39.8 ° c = _____ ° f
a. 100.2 b. 103.6 c. 102.1 d. 101.6
What is the major difference between research utilization and evidence-based nursing practice?
A) Research utilization is scientifically based; evidence-based nursing may not be. B) Evidence-based nursing uses one type of data; research utilization uses many types. C) Research utilization is used frequently in hospitals; evidence-based practice is not. D) Evidence-based nursing outcomes are better than research utilization outcomes.
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site
A student asks the nursing instructor whether it is important to be familiar with nursing theories. What should the instructor's response be?
1 . Nursing programs are based on nursing theories. 2 . Most theories include a definition of illness. 3 . Theories are often expressed in relation to factors, such as mind, body, spirit, and emotions 4 . Theories help to systematically develop decision-making skills. A) 1, 2 B) 1, 3 C) 1, 4 D) 2, 4