A patient with AIDS-related wasting syndrome is very weak, lies listlessly in bed, has an intravenous (IV) drip, and receives antiretroviral medications via injection. What should be the priority nursing diagnosis for this patient?
a. Pain related to immobility
b. Ineffective Individual Coping due to terminal stage of HIV
c. Risk for Injury due to impaired mobility, weakness, and weight loss
d. Risk for Infection due to weak immune system and parenteral therapy
ANS: D
In considering priority, the life-threatening risk is for infection due to weak immune system and parenteral therapy, so this is the priority. C. Risk for injury would be the priority after the Risk for infection. A. Additional information is needed to determine if the patient is experiencing pain. B. Ineffective coping can be the focus after life-threatening risks are addressed.
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After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)
a. "I'll read the nutritional labels on food items for salt content." b. "I will drink at least 3 liters of water each day." c. "Using salt in moderation will reduce the workload of my heart." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake."
The nurse is aware that a key sign of a brain tumor is:
a. morning nausea. b. difficulty reading. c. headache that awakens patient. d. increasing blood pressure.
When developing a care plan for a client with Parkinson's disease, the nurse would identify which of the following nursing diagnoses as the highest priority:
a. Altered nutrition, more than body requirements related to increased appetite. b. Deficient knowledge related to disease process and treatment regime. c. Impaired physical mobility related to hand tremors. d. Risk for injury, falls related to lack of coordination in movements.
A client who has an anxiety disorder fears having panic attacks when he is alone at home. The nurse teaches the client to use meditation techniques when he feels anxious
The technique can be evaluated as having proved useful when the client explains to a friend that meditation: 1. Is difficult to learn and requires a facilitator when doing techniques 2. Results in positive physical and mental effects 3. Is only beneficial to reduce mild anxiety 4. May result in increased anxiety