The nurse is planning care for a patient with a mental health disorder. Which nursing diagnosis should the nurse select if the patient is demonstrating manic behavior?
a. Grieving
b. Confusion
c. Risk for Injury
d. Defensive Coping
ANS: C
The patient with manic behavior is at risk for injury because of impaired judgment. A. The person demonstrating manic behavior has not necessarily experienced a loss. B. The person who is demonstrating manic behavior is not confused but rather acting impulsively. D. The person who is demonstrating manic behavior is not experiencing a situation in which defensive coping is necessary.
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Lila Jacobs is 80 years old and lives at home with her husband. She has Alzheimer's disease with increasing confusion and urinary incontinence. Mr. Jacobs has had a cerebrovascular accident and can no longer care for her in their home
What referral would you make for Mrs. Jacobs? a. Retirement center b. Intermediate nursing facility c. Skilled nursing facility d. Hospitalization
The nurse is assessing the client's neurologic system. The nurse tests the client's ability to perform stereognosis. Which activity will accurately test this?
1. The nurse places a vibrating tuning fork over the client's ankle and asks the client to indicate when the vibration can no longer be felt. 2. The nurse asks the client to close her eyes and writes the number '7' in the client's palm with the base of the nurse's pen. The nurse asks the client to identify what was written. 3. The nurse asks the client to close her eyes and places a pen in the client's hand. The nurse asks the client to name the object in her hand. 4. The nurse asks the client to close her eyes and indicate where the nurse is touching the client.
A patient has decrease mobility in all joints. Because of the lack of mobility, the nurse expects the health care provider to order what medication to prevent venous thromboembolisms that will reduce the side effect of hemorrhage?
a. Oral anticoagulant b. Aspirin c. Low-molecular-weight heparin d. Unfractionated heparin
The diagnosis of hypertension depends on accurate assessment of blood pressure (BP). What is the appropriate technique to measure a child's BP?
a. Assess BP while the child is standing. b. Compare left arm with left leg BP readings. c. Use a narrow cuff to ensure that the readings are correct. d. Measure BP with the child in the sitting position on three separate occasions.