During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood?

a. Affect depressed; mood flat
b. Affect flat; mood depressed
c. Affect labile; mood euphoric
d. Affect and mood are incongruent.


ANS: B
Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person's expression, the affect is flat.

Nursing

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You are assessing an 80-year-old patient who has presented because of an unintended weight loss of 10 pounds over the past 8 weeks

During the assessment, you learn that the patient has ill-fitting dentures and a limited intake of high-fiber foods. You would be aware that the patient is at risk for what problem? A) Constipation B) Deficient fluid volume C) Malabsorption of nutrients D) Excessive intake of convenience foods

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During a health history, the client looked confused and said, "But everybody drinks, like at parties and such. How much drinking do you think is too much?" Which of the following would be most appropriate response by the nurse?

a. "Alcohol should be used only in moderation." b. "It's okay as long as you don't binge, and you eat food with your drinks." c. "Per day, no more than one drink for women and two drinks for men." d. "Total abstinence is the only healthy choice."

Nursing

The nurse irrigates the client's right ear with saline solution to improve hearing. Which unexpected outcome of ear canal irrigation does the nurse prevent by preparing the irrigation so-lution properly?

1. Client hearing acuity remains stable. 2. Client senses irrigant is slightly warm. 3. Client complains of nausea and vertigo. 4. Client drainage contains brown particles.

Nursing

Which statement made by a new graduate nurse about invasive mechanical ventilation techniques is incorrect and requires additional teaching?

1. "Assist control mode refers to the patient receiving a set total lung capacity (TLC) but the rate can be modified by the patient's own rate of breathing." 2. "Total control mode controls both the rate and volume that are preset and delivered without the machine responding to any of the patient's own breaths." 3. "Synchronized intermittent mandatory ventilation (SIMV) refers to the patient setting an independent rate but limited tidal volume based on the patient's own strength. A minimum rate is also used as a backup to prevent hypoventilation." 4. "Continuous positive airway pressure will increase the residual capacity and keep the alveoli open. Rate and volume are controlled by the patient. This is one step in the weaning process."

Nursing