ANSWER AND RATIONALE Show 1. D, F, G, H 2. A, B, C 3. A, B, C, E 4. A, B, D, E 5. D, B, C, A 6. C, D, A, B 7. C, D, E 8. A, B, C, D 9. A, B A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5). 10. B, C, D The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase. 11. A, B Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it. 12. A, B, C, D Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful. 13. B, D, E Digoxin (Lanoxin) is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache, visual disturbances such as diplopia, blurred vision, yellow-green halos, photophobia, drowsiness, fatigue, and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. 14: B, C, D, G 15. A,
C, D 16. B, C, E, F 17. B,
D, E 18. B, A, E, C, D 19. A, D, E 20. D, F, G, H 21. A, B, C, D 22. C, A, D, B 23.
A, C, D, E, B 24. A, B, E B. Laparoscopic surgery involves insufflating the abdominal cavity with air, which is painful until it is absorbed. The amount of pain should be measured and documented with either a 1-10 scale or the Wong's FACES for younger children. C. A special diet is not indicated after this surgery. D. After a laparoscopic appendectomy, there is little drainage and no dressings. E. Auscultating for bowel sounds and documenting their presence or absence evaluate the child's adaptation to the intestinal trauma caused by the surgery. 25. A,B,D The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night is not indicative of impaired respiratory health. Which is the best time for patient teaching to occur?When is the best time for teaching to occur? Select all that apply. Rationale: Plan teaching when the patient is most attentive, receptive, alert, and comfortable.
What is the first step in the development of a patient teaching plan?The first step is to assess the patient's current knowledge about their condition and what they want to know. Some patients need time to adjust to new information, master new skills, or make short- or long-term lifestyle changes.
What is the most important first step when the nurse begins health teaching?Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
What should be included in patient's teaching plan?Your teaching plan should include what will be taught, when teaching will occur, where teaching will take place, who will teach and learn, and how teaching will occur. Deciding what will be taught is a decision you and the patient need to make together.
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