The home health nurse assesses a patient who creates elaborate excuses for not leaving home. Further questioning reveals the patient had not left home for 6 months. How should this be documented?
a. Mania
b. Depression
c. Agoraphobia
d. Anxiety
ANS: C
Agoraphobia is a high level of anxiety in which an anxiety attack could occur in individuals who avoid other people, places, or events.
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The manager is reviewing informatics competencies for each level of staff nurse. Which statement indicates the appropriate level of informatics competencies to the correct nurse?
A) An informatics nurse extrapolates data to develop a best practice model for indwelling catheter care. B) The novice nurse uses a spreadsheet to document medication reactions. C) An experienced staff nurse creates databases. D) A beginning nurse utilizes the Internet to integrate multidisciplinary languages.
Four clients are scheduled for surgery. Which client does the nurse determine is at highest risk for postsurgical complications?
a. 89-year-old scheduled for a knee re-placement b. 40-year-old requiring gallbladder surgery c. 19-year-old requiring a laparoscopy d. 10-year-old admitted for a tonsillectomy
The physician has prescribed phenytoin (Dilantin) for a client with diabetes mellitus, type
1. What does the nurse include in the plan of care for this client? 1. Plan to institute safety precautions, as the client is at risk for dizziness and ataxia. 2. Plan to discuss with the physician the need to increase the client's insulin based on serum glucose levels. 3. Plan to assess the client for petechiae, epistaxis, and hematuria. 4. Plan to discuss with the physician the need to decrease the client's insulin based on serum glucose levels.
The nurse instructs a client with which condition to avoid taking over-the-counter cough and cold remedies?
a. High blood cholesterol b. Rheumatoid arthritis c. Hypotension d. Thyroid disease