Which nursing diagnosis is not appropriate for a visually impaired adult patient?

A person with macular degeneration:

A nursing report on a newly admitted patient who is profoundly hard of hearing says that the patient is confused and difficult to assess because she does not appropriately respond to questions or sometimes fails to respond at all. What should be the first action of the oncoming nurse?

Chief Complaint:The patient reports feeling fatigued and experiencing frequent headaches for the past week. They also report generalized muscle weakness, which has worsened over the past few days. The patient notes that they have gained approximately 6 pounds (2.72 kg) over the last 5 days and states, “I need to sleep in my recliner at night because lying flat makes it hard to breathe.” Past Medical History: Hypertension Type 2 Diabetes Mellitus CHF Vital Signs at Admission: Blood Pressure: 120/80 Pulse: 104 bpm (apical, regular) Respiratory Rate: 24 breaths/min Temperature: 98 oral O2 Saturation: 95% RA The nurse recognizes the client is most likely experiencing (choose one and write the letter): A. atelectasis B.  fluid volume excess C. pneumothorax _______ as evidenced by (choose one and write the letter): A.  worsening dyspnea B.  muscle weakness C.  2+ radial pulses _______ and A.  capillary refill, less than 2 seconds B.  moist oral mucous membranes C.  weight gain _______

The nurse reviews the admission notes and nurse’s notes. Chief Complaint:The patient reports feeling fatigued and experiencing frequent headaches for the past week. They also report generalized muscle weakness, which has worsened over the past few days. The patient notes that they have gained approximately 6 pounds (2.72 kg) over the last 5 days and states, “I need to sleep in my recliner at night because lying flat makes it hard to breathe.” Past Medical History: Hypertension Type 2 Diabetes Mellitus CHF Vital Signs at Admission: Blood Pressure: 120/80 Pulse: 104 bpm (apical, regular) Respiratory Rate: 24 breaths/min Temperature: 98 oral O2 Saturation: 95% RA Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. fatigue and headache _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. muscle weakness _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. moist oral mucous membranes _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. Weight gain 6 lb (2.72 kg) over 5 days _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. Client states, “I need to sleep in my recliner at night.” Tachypnea, coarse lung crackles _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. 2+ radial pulses _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. apical pulse, 104, regular _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. bilateral lower leg edema _______ The nurse reviews the admission notes and nurse’s notes. Specify whether or not the this finding requires follow up by the nurse by typing follow up or no follow up. Client states, “I need to sleep in my recliner at night.” _______

What information should a nurse include when providing information to a patient using topical eye medications?

Hypovolemic shock occurs when there is low fluid volume in the:

What is shock?

_____________ fluids remove water from the extracellular space into the intracellular space.

You are caring for a patient that had an a left knee replacement.  She is complaining of shortness of breath and pain in her chest.  You suspect she may have a pulmonary embolism and know that if you do not intervene she could go into: