Answer to Question 1
Correct Answer: 2
Rationale 1: Health-Seeking Behavior is a diagnostic label used when the client is seeking health information.
Rationale 2: The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has identified a learning need, as in this case. The area of deficiency (diet and medication regimen) should always be included in the diagnosis.
Rationale 3: Noncompliance is used when the client or caregiver fails to follow a plan, which is too early to tell in this case.
Rationale 4: Risk for Myocardial Infarction is not a NANDA label. If a risk exists, the label could be Risk for Noncompliance related to deficient knowledge.
Answer to Question 2
Correct Answer: 3
Rationale 1: Learning outcomes, like client outcomes, must be specific and observable so they can be measured. Words like understand are not measurable and are not observable.
Rationale 2: Be able to lose weight is not specific enough, and with the information given, it is not known if that is really what the client wants to attain.
Rationale 3: Learning outcomes, like client outcomes, must be specific and observable so they can be measured.
Rationale 4: Words like appreciate are not measurable and are not observable.
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
The nurse applies a pulse oximeter sensor on the client’s finger.
(A) Unwrap each of the layers until the client is covered by just the plastic sheet and the towels ...
A hot stone placed under the client’s neck.
Positioning the client
The physician orders pemetrexed (Alimta) 500 mg/m2. The client’s body surface area is 2.14 ...