A 16-year-old client says, "My dad thinks I'm evil, but we get into fights because I let things build up. He never has any time for me because he's always glued to the TV. He doesn't even look at me when he talks." Which statement by the nurse encourages the client to use assertive behavior with his father?
A. "So you're saying that you let your feelings build up and then you just explode?"
B. "Have you tried standing in front of the television when your dad is watching it?"
C. "What makes you feel that you have the right to fly off the handle just because you feel ignored?"
D. "Have you tried saying that directly to your dad? For example, you could say, 'I notice that you watch television when I'm telling you things that are important to me.'"
Ans: D. "Have you tried saying that directly to your dad? For example, you could say, 'I notice that you watch television when I'm telling you things that are important to me.'"
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A patient is admitted to the ICU for observation of his grade II splenic laceration. Which of the following signs and symptoms would suggest that he has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock?
a. BP, 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/hr; skin that is pink, warm, and dry with capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/hr; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/hr; flushed, warm, diaphoretic skin; agitated and confused
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 61-year-old man is being admitted for bariatric surgery. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP)?
a. Demonstrate use of the incentive spirometer. b. Plan methods for bathing and turning the patient. c. Assist with IV insertion by holding adipose tissue out of the way. d. Develop strategies to provide privacy and decrease embarrassment.
During assessment of a young adult woman, the client's 3-year-old child is constantly climbing over her and trying to get things out of her mother's purse. An appropriate response by the nurse is to:
a. Give the child a word-puzzle book. b. Request the client take the child out to the waiting room. c. Give the child paper and crayons to draw pictures. d. Ask the client to come back when the child is not with her.