Which question should the nurse ask to determine whether the client has been experiencing anxi-ety?
1. "Have you had more difficulty concentrating lately?"
2. "Have you been feeling sad and lonely?"
3. "Do you have a history of nerves?"
4. "Do you frequently feel angry and upset?"
ANS: 1
Concentration difficulties occur when moderate or greater levels of anxiety are present. Option 2 assesses mood. Option 3 is a misnomer and would not necessarily provide accurate data. Option 4 assesses aggressive or anger symptoms.
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An adult client who resides in a long-term care facility is diagnosed with osteoporosis. The client has a history of falls and dementia. Which nursing intervention will best aid in meeting an outcome goal of injury prevention for this client?
A) Using furniture as obstacles to keep the client in the bed B) Keeping the bed in the lowest position C) Keeping a nightlight on in the room D) The use of wrist restraints
The nurse is participating in a nursing research study based upon a particular nurse theory. The nurse is ultimately helping to develop:
a. standardized nursing care plans. b. protocols. c. nursing practice standards. d. client discharge criteria.
Which of the following statements about family-focused chronic illness case management is accurate?
1. Family-focused chronic illness case management focuses on the individual family member with the chronic illness. 2. Family-focused chronic illness case management begins with a nurse sharing advice with family members. 3. Family-focused chronic illness case management may lead to delayed or prevented complications. 4. Family-focused chronic illness case management determines certain family members with whom to communicate.
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?
a. Elevate the head of the bed to 45 degrees. b. Apply a sterile 2-inch gauze dressing to the site. c. Use a half-inch sterile gauze to pack the wound. d. Have the patient lie on the left side for 1 hour.