Using the scenarios listed below, write 2 sample nursing diagnoses…

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Question Using the scenarios listed below, write 2 sample nursing diagnoses… Using the scenarios listed below, write 2 sample nursing diagnoses (1 actual, 1 potential) and write 2 expected outcomes for the patients described.   A mother visits her pediatrician for a well-baby checkup. She tells the nurse that she is having trouble keeping her baby’s scalp from crusting over and peeling. She also states that her baby is experiencing worse than normal diaper rash.A new mother visits the pediatrician for a well-baby checkup. During the nursing assessment, she tells the nurse that she always lays the baby to sleep on her stomach because she tends to throw up during the night. She also asks if it is okay to use a baby blanket because their bedroom is cold at night.A father brings his newborn son to the free clinic for a checkup. During the family assessment, he confides to the nurse that he sometimes gets frustrated with the infant when he cries and although he states that he knows he can’t do it, he is tempted to “shake him” when he won’t sleep. Health Science Science Nursing NCM 100 Share QuestionEmailCopy link Comments (0)

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Question 41, during anaphylactic shock, the body reacts by rapidly... 41, during anaphylactic shock, the body reacts by rapidly vasodilating blood vessels , the body's response also includes an airway reaction to histamine. What is the expected airway response during anaphylaxis?A, bronchophony B, bronchodilation 42. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the actions should the nurse take? Select all that applyA. Elevate the client's head of bedB. Insert a urinary catheterC.Apply a cervical collar to the client.D Monitor the puncture site for hematomaE. Encourage fluid intake.43. A client is admitted to the medical surgical unit with a diagnosis of gastrointestinal bleeding. The nurse noted that the client's hourly urine output is decreasing. What is the normal output of urine per hour?A. 30ml/hrB. 100 ml/hr  44, a client in hypovolemic shock , the nurse knows that with any type of shock , there will be a decrease in circulating blood volume resulting in decreased tissue perfusion. The inadequate tissue causes what observable sign in the client evaluation?Flushed skinVasodilationIncreased urine outputDelayed capillary refill45.A nurse is collecting data on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority.A.      the client has a heart rate of 122 beats per minuteB.      The client reports immediately discomfort at the burn siteC.      The client has a cough productive of black colored sputumD.      The client has a first degree burn on their hands46, nursing care for a client who is admitted with frostbite of the includes which of the following A, giving the client hot fluids to drinkB, applying a heating pad to the frostbitten area C, immersing the foot in warm water D, wrapping the foot unwarmed blankets  47, the client receiving mechanical ventilation has became more restless throughout the shift which is the nurse's first action/A , call the health care provider B, sedate the client  C, evaluate the client for pain D, evaluate the clients oxygenation  49. A client presents to the outpatient clinic with a two-day history of fever, fatigue, coughing and difficulty breathing. She is short of breath and unable to speak in complete sentences. What is the priority action?A. Review the physician orders and implement.B Obtain blood pressureC. Obtain oxygen saturation. 51, what is the priority action for the nurse to take if phlebitis infection at iv site is suspected?A, elevate the extremity B,remove the catheter C, apply continuous heat D, continue to monitor site  52. Which of the following interventions should the nurse identify as the priority for a long-term care client who is receiving mechanical ventilation?A. Suction the airway as needed.B.Providing a communication board for the clientC.Begin continues the feeding through a nasogastric tube.D.Application of antiembolism stockings.53.Which client needs to be placed immediately in isolation?A. A probable cause of inhalation anthraxB.suspected smallpox, but probable chickenpoxC.A client diagnosed with botulism poisoning54, a nurse is caring for a client in a rehab center who is being treated for partial -thickness and full-thickness bums of his head , neck, and chest. A client who sustains bums on their face, neck , and chest is most at risk for which of the following?A, infection B, airway obstruction C, fluid and electrolyte imbalance D, loss of motor function 55, older adult clients often have fragic skin. To help prevent skin tears , which of the following interventions would be the best option when initiating a peripheral iv?A, slap the skin vigorously to cause the vein to riseB, avoid the use of a tourniquet if the vein is arady hard C, use a blood pressure cuff to cause the vein to distend D, place a gauze pad under the tourniquet before tightening  56, in a disaster triage situation, which of the following is an example of the emergent (red tag) category?A , a client who has a punctured temporal artery B, a client who exhibits manifestations of multiple organ failure C, a client who has several closed fractures with bruising D, a client who has an open fracture  57, a client has suffered a deep laceration to the femoral artery. Which type of sock would the nurse anticipate?A, hypovolemic B, neurogenicC, cardiogenic D, septic 59. Clients who are receiving mechanical ventilation are at risk for pneumonia. Which of the following actions will help decrease the risk of pneumonia? Select all that apply.A. Handwashing before and after contact with the client.B. Administering antibiotic prophylaxisc. Placing the clients in a negative airflow room. 60,the plague was caused by bacteria found in rodents and fleas. The plague is on the list of bioterrorism agents , as a part of the disaster preparedness team the nurse is required to know the signs and symptoms of the plague , what are the signs and symptoms of the plague?A, hemoptysis , high fever, headache , respiratory failure B, nausea, vomiting , anorexia C, fever, backache, pustular lesionsD, swollen lymph nodes, edema 62. The CDC has identified an outbreak of cholera in a small remote village. The nurse volunteers to treat victims and educate the village on preventative measures. What would the nurse focus on in teaching the people that live in the village? Select all that apply.A. Boil water before drinkingB. Prevent raw sewage from entering water sources.C. Cook food well before eating.D. Handwashing.E. Proper wound care 63.A client receiving gentamicin intravenously reports that she is itching and has a rash on her arms. What is the priority action in this situation?A, change the iv insertion site to a new location B, stop the infusion of the drug immediately C, report the clients problem to the primary health care provider D, document findings anti actions in the electronic record 64, To evaluate effectiveness of lasix and morphine for treatment of pulmonary edema the nurse would do which of the following A, assess for decreased painB, check the strength of peripheral pulses C, monitor intake and outputD, assess respiratory status   65) A nurse is working in an ambulatory clinic. A client enters the room and is bleeding profusely from a deep laceration of his left lower forearm. After donning gloves what is the priority actionA. Sit the client in the chair with the legs elevatedB. Application of tourniquet to the left armC. Elevate the extremities above the heartD. Application of direct pressure to the wound  66) Which of the following is the early symptoms of shockA. HypotensionB. BradycardiaC, bradypnea D, irregular heart rhythm  67) Which of the following is a high priority in the immediate treatment of chemical the burns of the handsA. In all cases apply water to cool the burnB. In most cases except for dry lime, flush with large amount of water to remove the chemicalC. Use alcohol to clean the chemical off the skinD. Cover the burn with the dressing but do not flush the chemical from the skin 68) Which of the following is the responsibility of the nurse during the disaster?A. Maintain the appropriate stock in the unitB. Reinforce discharge teaching to clientsC. Focus on client with life threatening emergenciesD. Delegate the Aps to focus on the client's ADLs 69. A client who has taken their first dose of penicillin reports shortness of breath and a red rash on their chest and abdomen. Which of the following medications would be administered first?A. DiphenhydramineB. Hydrocortisone sodium succinateC. AlbuterolD. Epinephrine 70. A client is in cardiogenic shock with significant hypotension. What position would increase the blood flow to the brain? A. Supine with legs elevated.B. High fowlers  C, semi-fowlers D, side-lying 71. Smallpox was eradicated in the US in 1971 due to the development of a vaccine. Smallpox is listed in the category of bioterrorism agents. How is smallpox transmitted as a biologic agent?A Contamination watersB ContactC AirborneD Indirectly in food sources 72. A nurse is observing the care of a client in the emergency department. The client reports severe radiating chest pain and shortness of breath. The client is restless. Slightly cyanotic and reports being frightened. The provider prescribes oxygen by nasal cannula at 4l/min stat. cardiac enzyme levels. IV fluids. And a 12 lead ECG. Which of the following actions will be taken first?A. Application of oxygen at 4l/minB. Inserting the peripheral.C. Semi Fowlers.D. Side lying 73) A nurse is attending a yearly training about triaging after a mass casualty event. Which of the following clients would receive priority care?A. A client who has a circular partial thickness of their handB. A client who has an open fracture of the humerus.C. A client with a large head lacerationD. A client who has severe respiratory distress 74. A Nurse is preparing to exit an isolation room. Which of the following pieces of personal protection equipment (PPE) should the nurse remove last?A EyewearB GownC GlovesD Mask  Health Science Science Nursing NURSING 155 Share QuestionEmailCopy link Comments (0)
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