A male client displaying acute mania has disrobed in the hall three times in 2 hours. The nurse
should
a. direct the client to wear his clothes at all times.
b. ask if the client finds the clothes bothersome.
c. tell the client he is embarrassing the women.
d. arrange for one-on-one supervision.
D
A client who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one
supervision may provide the necessary structure. Option A has not proven successful. Option B
serves no purpose. Option C will not make a difference to the client whose grasp of social behaviors
is impaired by the illness.
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The patient should be assessed as soon as possible after admission. This initial assessment is done by the:
a. physician. b. charge nurse. c. LPN/LVN. d. RN.
Which nurse should be assigned to a dying client who is experiencing symptoms of emotional distress?
a. Unlicensed assistive personnel (UAP) who can be spared to sit with the client b. Licensed practical nurse (LPN) who has grown attached to the family c. RN who has experience as a hospice nurse d. Newly graduated RN
An older adult with heart failure and mild dementia states the intent to refuse low sodium diet and diuretics, stating: "It's important to me to live free, without restrictions on what I eat." The family is supportive. Which action, by the nurse
should be done first? A) Assure that the client understands the consequences of this decision. B) Discuss this decision with the older adult's family to plan for the future. C) Document the client's wishes in the plan of care. D) Notify the primary health care provider of the client's wishes.
Following a unilateral adrenalectomy, nurse Betty would assess for hyperkalemia shown by which of the following?
a. Muscle weakness b. Tremors c. Diaphoresis d. Constipation