The nurse learns that a patient of the Jewish faith does not eat certain types of foods and fasts on religious holidays. What should the nurse do to ensure that this patient's needs are met?
1. Report the patient's needs to the oncoming nurse.
2. Document the patient's preferences on the assessment form.
3. Talk with the dietitian to obtain food preferences for the patient's meals.
4. Explain to the patient that eating is needed to maintain nutritional status.
3
Rationale: The nurse needs to do more than report the patient's needs to the oncoming nurse.
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The nursing student taking care of a client in the mental health clinic learns through assessment that the client's wife insisted he admit himself into the clinic even though his wife is the one with a documented history of mental illness
The client states, "I just want her to be happy." The nursing student suspects that the client's relationship with his wife may be: 1. Enmeshed. 2. Disengaged. 3. Hostile. 4. Skewed.
The nurse evaluates the client as experiencing symptoms of disequilibrium syndrome, following an initial hemodialysis treatment. Which is the best action to be taken by the nurse?
A) No action is needed. B) Hold the next scheduled treatment. C) Slow the dialysis process during future treatment. D) Notify the physician and manage the symptoms.
The nurse is providing education to a patient with cystic fibrosis (CF) who is beginning therapy on tobramycin (TOBI). What symptom associated with tobramycin should the nurse advise the patient to report?
a. Hearing loss b. Blurred vision c. Ringing in the ears d. Bleeding gums
A client is in the second stage of shock. Which of the following would the nurse most likely assess? (Select all that apply.)
a. Oliguria d. Restlessness b. Tachypnea e. Hemodynamic insta-bility c. Agitation and confu-sion f. Tachycardia (100–120 bpm)