224) Which of the following nursing diagnoses has the highest priority for a client with a missed abortion who has developed disseminated intravascular coagulopathy (DIC)?

A) Anticipatory Grieving

B) High Risk for Deficient Fluid Volume

C) High Risk for Injury

D) Spiritual Distress

ANSWER

223) A nurse received an order to initiate early ambulation with a post appendectomy patient. The nurse recognizes this activity to be helpful in preventing possible complications associated with prolonged bed rest. To assist her to start walking after surgery, the nurse will:

A. The nurse begins assisting the patient to sit at the edge of the bed. Then, instruct her to stand at the bedside, and then walk around the room

B. With 15 minute intervals, the nurse begins to position patient into high-fowler’s, then instructs her to dangle her feet at the bedside, after this, she assists her to move from the bed to the chair and then, walk with her around the room

C. The patient is instructed to pull herself up in bed and allow to sit at the edge of the bed then immediately stand and walk around the room

D. The patient is instructed to sit at the edge of the bed and rest for a few minutes then stand at the bedside and try to walk around the room.

ANSWER

222) The nurse is caring for a 2-year-old with acute otitis media. Which of the following instructions should be included in the teaching plan for the parents of the child?

A. Finish the course of antivirals, even after symptoms disap-pear

B. Avoiding contact with people who have upper respiratory in-fections

C. Place the child in a supine position to bottle feed

D. Clean the inside of the ear canals with cotton swabs

ANSWER