A patient tells the nurse that he hears a loud fire alarm when in reality there is no alarm. The nurse realizes this patient is experiencing:
a. disorientation c. sensory overload
b. sensory deprivation d. auditory hallucination
D
There is no evidence to suggest that this patient is experiencing disorientation, sensory deprivation, or sensory overload. This patient is perceiving sounds that are not present in the environment or an auditory hallucination.
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A child has had an episode of lip smacking while staring into space, but did not seem to lose consciousness. She was confused afterward but said her hands felt tingly before the other symptoms started. How should the nurse document this event?
A. Alteration in consciousness B. Convulsion C. Focal seizure D. Generalized seizure
A long-term care facility is the site of an outbreak of infectious diarrhea. The nurse educator has emphasized the importance of hand hygiene to staff members
The use of alcohol-based cleansers may be ineffective if the causative microorganism is identified as what? A) Shigella B) Escherichia coli C) Clostridium difficile D) Norovirus
If the client's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take?
a. Document the finding. b. Tell the health care provider. c. Begin antibiotic therapy immediately. d. Have the laboratory draw blood for reanalysis.
A health care facility determined that a nurse employed on a medical unit was documenting care that was not being given, and subsequently reported the action to the State Board of Nursing. How might this affect the nurse's license to practice nursing?
A) It will have no effect on the ability to practice nursing. B) The nurse can practice nursing at a less-skilled level. C) The nurse's license may be revoked or suspended. D) The nurse's license will permanently carry a felony conviction.