A patient is on strict bed rest for 5 days. During this time he has not had a bowel movement; normally, he passes stools daily. He describes feeling bloated and uncomfortable
A nursing diagnosis that would best address a patient who is on bed rest is Constipation related to:
1) Change in previous pattern.
2) Immobility.
3) Dietary intake.
4) Change in environment.
ANS: 2
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A client with paranoid schizophrenia is experiencing visual hallucinations of people jumping out of nowhere. The client keeps striking the wall
Repeated attempts by the nurse to orient the client to reality and reassure the client of safety have failed. What would be the nurse's next de-escalation approach? 1. Offer the client a PRN medication 2. Apply soft limb restraints on client's wrists 3. Have several staff demobilize the client so that forcible injection can be administered 4. Call security to assist in placing the client in seclusion
Before beginning postural drainage on a patient, the nurse should do which of the following?
A) Allow the patient to eat. B) Auscultate breath sounds. C) Take vital signs. D) Perform chest percussion.
The nurse observes the newly hired unlicensed assistive personnel (UAP) performing routine client care. Which behaviors would indicate the UAP understands the use of personal protective equipment?
1. The UAP removes his gown first and then his gloves after providing care. 2. The UAP applies gloves before emptying the client's indwelling catheter bag, then removes gloves and washes hands before measuring urine output. 3. The UAP applies gloves to clean the client's dentures, then removes gloves and performs hand hygiene prior to bathing the client. 4. The UAP wears gown and gloves when performing postmortem care.
As the nurse discusses the discharge plan with a recovering patient, the most effective communication technique to use is:
1. assessing nonverbal clues. 2. allowing communication to focus on whatever topic the patient desires. 3. insisting on postrecovery activities as stated in the care plan. 4. reducing eye contact to convey nondirective attitudes.