11 Jun A patient who experienced a traumatic
Question
A patient who experienced a traumatic amputation of the leg tells the RN ill never be the same without my leg” The RN identifies grieving as the nursing diagnosis. Which considerations are necessary for establishing an outcome for this patient- SELECT ALL THAT APPLY
describe the desired resolution of the problem
provide examples of outcomes previously useful with other patients
collaborate on an outcome realistic to the patient
inquire about the patients culture and religious beliefs
ask about the personal meaning of the loss
which statement made by the parent to the RN raises concerns about a childs risk for maltreatment? SELECT ALL THAT APPLY:
I really did not plan or want to have children until i finished school
somedays it takes all my energy to get out of bed
i wish my child would not cry when my new significant other is present
a glass of wine during the day helps me cope with the stress of parenting
I restricted use of all electric toys because of my childsbehavior
The RN prioritizes the nursing diagnosis of deficient fluid volume, acute pain and risk for infection for a patient in the emergent resuscitativephase of a second degree burn. As the patient enters the rehabilitationphase what changes are made in the patients plan of care?
change deficient fluid to a risk for diagnosis
initiate the nursing diagnosis of ineffective coping
resolve the risk for infection after the acute resuscitative phase
identify the patient as a risk for post traumatic syndrome
a woman with sub-fertility tells the RN i know why am having difficulty i had an abortion as a teenager and now I’m being punished. what is an approbate nursing diagnosis for this woman?
ineffective self help management
spiritual distress
powerlessness
deficient knowledge
which nursing interventions would move a patient with ineffective airway clearance towards the outcome of the patient will demonstrate clear breath sounds?
SELECT ALL THAT APPLY
elevate the HOB at 45 degree
administer influenza vaccine prior to discharge
administer oxygen at prescribed rate
encourage activity and ambulation
a patient seeks medical care for fatigue, noctura, urinary frequency and urgency. what additional data cue supports the nursing diagnosis of urninary retention?
tympanic sounds when abdomen is percussed
mild discomfort in the pelvic area
residual of urine 75ml
hematuria
a pregnant woman in the third trimester develops sudden sharp abdominal pain with vaginal bleeding which nursing diagnosis indicates a priority problem?
risk for deficient fluid volume
risk for impaired gas exchange
ineffective childbearing process
acute pain
A RN completing a health history on an older adult, which remark is appropriate when beginning to inquire about sexual health?
I have to ask the next few questions on sex
let me put the curtains around the bed before we discuss this topic
how is your relationship with your partner
since your spouse recently died, do you want to skip the questions on sex
what symptoms reported to the rn by the pregnant woman in the third trimester is an unexpected but significant finding that requires prompt reporting to the health care provider
inability to lie flat
dyspnea on exertion
nighttime cough
frequent urination
a patient with a new diagnosis of cancer tells the RN I just dont know what to do, several members of my family had cancer and the treatment was difficult. which is the priority nursing diagnosis
deficient knowledge
decisional conflict
self care deficient
ineffective health maintenance
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