Author Question: The nurse listens as the physician informs the client of the diagnosis of colon cancer and explains ... (Read 59 times)

lidoalex · **on:** Jul 22, 2018

The nurse listens as the physician informs the client of the diagnosis of colon cancer and explains the need to remove the colon and create an ileostomy. When the physician leaves, the nurse's priority diagnosis is:

1. Risk for PerioperativePositi oning Injury.
2. Risk for Disuse Syndrome.
3. Risk for Ineffective Coping.
4. Knowledge Deficit.

Question 2

An 88-year-old female client with osteoporosis has been admitted to the long-term care facility. She has a history of falls and dementia.

Which of the following interventions by the nurse will best aid in meeting an outcome goal for injury prevention? 1. The use of wrist restraints
2. Using furniture as obstacles to keep the client in the bed
3. Keeping the bed in a low position
4. Keeping a nightlight on in the room

Cheesycrackers · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3. Risk for Ineffective Coping.

Rationale:
The client and family will require support to deal with their emotional response to learning the client has cancer and will undergo body-image changing surgery. Disuse syndrome and injury from positioning may be factors after surgery. Now is not the time to begin instructions because the client will most likely be unable to learn or concentrate on what the nurse is teaching.

Answer to Question 2

3. Keeping the bed in a low position

Rationale:
Keeping the bed in a low position will reduce the incidence of injury should the client attempt to get up. The use of restraints could increase the incidence of injury. Using the furniture as an obstacle could cause injury if the client is able to get up. A nightlight is useful but is not the best means to prevent injury.