The nurse observes a withdrawn schizophrenic. The patient is sitting alone and moving her lips as if she is talking, but there is no audible sound. The nurse speaks to the patient by name, but the patient does not seem to hear
What should the nurse do first?
a. Hug the patient's shoulders, refer to the patient by name, and ask if she's praying.
b. Document the patient's nonresponsiveness and continued detached behavior.
c. Sit down in the chair next to the patient, touch her arm, and speak softly.
d. Touch the patient's shoulder and then join another group of patients.
C
Sitting with the patient and touching her presents the reality of the nurse's presence. Continued attention will make the patient feel safe. Feelings of safety are needed in the beginning of the nurse–patient relationship. Hugging the patient may invade the patient's personal space. The nurse's assessment will be documented but it is most appropriate to attempt an interaction with the patient.
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a. Unidactyly. b. Syndactyly. c. Polydactyly. d. Multidactyly.
The nurse is making a home visit to a client who had a cesarean birth 3 days ago. Assessment reveals that she is complaining of intermittent pain, rating it as 8 on a scale of 1 to 10
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Biopsy reveals that a patient has a single papilloma in her right breast. The lesion was completely removed during the biopsy procedure. What information would the nurse reinforce regarding this patient's future breast cancer risk?
1. The patient has breast cancer at present. 2. The patient is at no greater risk for breast cancer in the future. 3. The patient is at some increased risk for breast cancer, generally about 1.5 to 2 times the normal risk. 4. The patient's risk for future breast cancer is very high, generally 10 to 20 times the normal risk.
A patient who is using atropine eyedrops is found to have a poor consensual light response. The nurse recognizes that this finding is considered:
1. abnormal and should be reported to the physician. 2. normal because of the eyedrops. 3. evidence of retinal degeneration. 4. evidence of optic nerve damage.