A client is diagnosed with encephalopathy as a result of opportunistic infections
following human immunodeficiency virus (HIV) infection. What nursing diagnosis
should the nurse document it as?
A) Ineffective breathing pattern
B) Impaired tissue integrity
C) Risk of disuse syndrome
D) Disturbed thought process
D
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A patient, age 72, has a left intertrochanteric fracture as a result of a fall. In planning ways to increase her safety, the nurse realizes it is most important to determine
a. preexisting health conditions. b. nutritional status. c. psychosocial history. d. pain level.
A parent brings a 3-year-old child to the clinic with a complaint of a painful elbow. The pediatrician orders an X-ray, which reveals the child has a dislocated elbow. The pediatrician or the office nurse will:
a. immediately call and report suspected child abuse b. assess to see if this injury is related to rough play with other children c. talk with the family about not forcibly lifting the child by the hand d. question the parent to ascertain who might be abusing the child
A Native American patient describes a difficult childhood and dropping out of high school. The patient abused alcohol as a teenager to escape feelings of isolation but stopped 10 years ago. The patient now says, "I feel stupid. I've never had a good job
I don't help my people." Which nursing diagnosis applies? a. Risk for other-directed violence b. Chronic low self-esteem c. Deficient knowledge d. Social isolation
A healthy postoperative patient who has been on bedrest for 3 days develops sudden dyspnea, tachypnea, restlessness, and chest pain. The patient says, "I feel as if something is going to happen to me." What should the nurse do?
a. Ensure physician is notified immediately. b. Perform a bilateral Homans' test. c. Give a narcotic for pain as ordered. d. Reassure the patient that everything is fine.