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). Show 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. What are the surgical risk factors?Surgical risk factors include direct intraoperative trauma or stretch, vascular compromise, perioperative infection, hematoma formation, prolonged tourniquet ischemia, or improperly applied casts or dressings.
What were the 3 main problems of surgery?Before surgery could become a safe and reliable treatment, three problems had to be overcome:. How to stop blood loss so the patient didn't bleed to death or go into shock.. How to deal with the excruciating pain of surgery and.. How to prevent life-threatening infections.. Which of the following increases the risk of wrong site surgery?The Joint Commission has identified the following factors that may contribute to an increased risk of wrong-site surgery: Multiple surgeons involved in the case. Multiple procedures during a single surgical visit. Unusual time pressures to start or complete the procedure.
What is a high risk patient for surgery?The high-risk surgical patient. High-risk operations have been defined as those with a mortality of >5%. This can be derived either from a procedure with an overall mortality of >5% or a patient with an individual mortality risk of >5%. Simple clinical criteria can be used to identify high-risk surgical patients.
|