An appropriate outcome for the treatment plan of a client with grandiose thinking associated with
acute mania would be that the client will demonstrate
a. a more optimistic outlook.
b. uncompromised sleep.
c. interest in his or her environment.
d. distorted thought self-control.
D
The desired outcome is that the client will be able to control the grandiose thinking associated with
acute mania as evidenced by making realistic comments about self, abilities, and plans. Options A
and C: Clients with acute mania are already unduly optimistic as a result of their use of denial, and
they are overly interested in their environment. Option B: Uncompromised sleep is a desired
outcome but is not related to distorted thought processes.
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Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct?
a. "It should fall off in 10 to 14 days." b. "It will soften before it falls off." c. "It contains two veins and one artery." d. "Skin will cover the area within 1 week."
The clinic nurse measures the client's blood pressure and obtains a reading of 144/82. The client's baseline blood pressure has been normal. For what factors would the nurse assess the client based on the current blood pressure reading?
1. Diet 2. Medication history 3. Activity 4. History of recent symptoms of hypertension 5. Recent stress factors the client has experienced
Subtract 0.068 from 5.543
1. 4.863 2. 5.475 3. 5.863 4. 5.5362
A client in the intensive care unit has a "do not resuscitate" (DNR) order on his chart. What does the nurse caring for him need to recognize about DNR orders?
a. DNR orders may be given orally by the physician. b. There is no specific time limit to DNR orders. c. DNR orders protect the client's family from making difficult decisions. d. DNR orders must be written by the physi-cian.