The nurse is caring for an AIDS patient who has been experiencing fatigue, anorexia, weight loss, and occasional nausea/vomiting. Which nursing diagnosis is the priority for this patient?
a. Fatigue
b. Imbalanced nutrition: Less than body re-quirements
c. Activity intolerance
d. Ineffective health maintenance
B
With all of these factors, the most appropriate nursing diagnosis would be Imbalanced nutrition: Less than body requirements. Interventions can be directed toward restoring nutrition, which may lead to less fatigue and weight loss.
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You are caring for an older adult client with an IV infusing at 100 mL/hr. What should you monitor this client for?
A) Urinary retention B) Circulatory overload C) Pulmonary embolism D) Incontinence
The nurse assesses an older client reporting mouth pain. What additional actions should the nurse take at this time? Select all that apply.
1. Review vital sign trends. 2. Auscultate all lung fields. 3. Palpate the face for tenderness. 4. Assess the client's oral mucosa. 5. Feel for enlarged lymph nodes around the jawline.
A patient who is a heroin addict is admitted to a methadone substitution program. After administering the first dose of methadone, the nurse notes that the patient shows signs of euphoria and complains of nausea. What will the nurse do?
a. Administer nalmefene (Revex). b. Contact the provider to obtain an order for naloxone (Narcan). c. Question the patient about heroin use that day. d. Suspect that the patient exaggerated the amount of heroin used.
Women with GDM cannot metabolize concentrated simple sugars without a sharp rise in
blood glucose. Name five examples of simple sugars you would teach Y.L. to limit. What will be an ideal response?