A client with catatonic schizophrenia is semistuporous, demonstrating little spontaneous movement
and waxy flexibility. The client's self-care activities of daily living have been assessed as severely
compromised.
An appropriate outcome would be that the client will
a. demonstrate increased interest in the environment by the end of week 1.
b. perform self-care activities with coaching by the end of week 1.
c. gradually assume the initiative in self-care by the end of week 2.
d. accept tube feeding without objection by day 2.
B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to
perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing
the tasks with coaching by nursing staff denotes improvement over the complete inability to perform
the tasks. Option A is not directly related to self-care activities. Option C is difficult to measure.
Option D is related to maintenance of nutrition.
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A patient who has been taking lovastatin (Mevacor) has seen an improvement in his cholesterol laboratory values; however, the low-density lipoprotein remains elevated. What medication will be added to the medical regime?
A) Digoxin (Lanoxin) B) Vitamin D C) Cholestyramine (Questran) D) Calcium carbonate
The nurse identifies the diagnosis Risk for Injury as appropriate for a client with metabolic acidosis. Which strategies should the nurse use to support this diagnosis?
Select all that apply. A) Apply wrist restraints and secure to the bed frame. B) Discuss chemical restraint use with the healthcare provider. C) Keep the bed in the lowest position. D) Keep bed side rails raised. E) Place a clock and calendar at the bedside.
You see a school-aged child in an ambulatory setting because of rheumatic fever. Which of the following would you expect to find revealed by the health history?
A) Knee pain, abdominal rash, subcutaneous nodules B) An elevated temperature, back pain, loss of hair C) Fatigue, slow pulse, frequent urination D) Loss of weight, abdominal pain, chest pain
The nurse knows that which of the following does not put a client at added risk for falls?
1. wearing eyeglasses 2. experiencing intermittent dizziness 3. having impaired memory and judgment 4. having noticeable weakness