Nursing 211

N211: Health Differences Across the Lifespan I 33. Hematuria without dysuria a. Rationale: Hematuria (blood in the urine) without dysuria (painful urination) is the most common symptom of bladder cancer. 34. Prepare for hemodialysis a. Rationale: Plasmapheresis (a form of hemodialysis) is used when a patient with multiple myeloma shows signs of increased serum viscosity. 35. Ineffective breathing pattern related to fear and pain 36. Shortness of breath and restlessness 37. Apply lotion to the hand of the affected side instead of cutting cuticles. a. Rationale: Trauma such as skin breaks is the primary cause of lymphedema, so trimming the cuticles should be avoided. 38. Establish a trusting relationship 39. Limit the patient’s exposure to visitors while treatment is being given. a. Rationale: Visitors should be protected from long exposure to the radiation source, and the patient should have limited contact because of the risk of infection while the radiation 40. I’ll limit swimming in my pool to twice a week. a. Rationale: Swimming may pose unnecessary risks because of skin irritation and exposure to sources of infection 41. Depressed nasal bone and protruding tongue 42. Behavior changes may be a sign of shunt dysfunction 43. Oranges and bananas 44. Indomethacin (Indocin) a. Rationale: Indocin inhibits platelet function and effects renal function 45. Observe for abdominal distention a. Rationale: Secondary to catheter placement, colony stimulating factor may cause peritonitis or a postoperative ileus. 46. Allow the mother to express her feelings about post-discharge counseling. 47. Altered nutrition: less than body requirements related to physical defect. 48. The family is of Ashkenazi Jewish origin. 49. I’ll observe your technique and then you can participate in your child’s care as much as possible.” 50. Minimal pulmonary complications 51. “Have you recently injured yourself?” a. Rationale: Because of the risk of bleeding during thrombolytic therapy, a recent injury should be investigated further before starting the therapy, to ensure that protective clots are not dissolved. 52. Apply oxygen via nasal cannula. a. Rationale: To minimize myocardial intervention is the highest nursing priority? 53. Anxiety increases the body’s oxygen demand.


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