The nurse has identified a diagnosis of dissociative identity disturbance for a client who has stated that he is unable to distinguish between himself and his surroundings. An outcome related to this diagnosis is that the client will:
1. Suppress feelings of dissatisfaction
2. Refer to himself as "the client"
3. Use aggressive behaviors to meet needs
4. Identify increasing anxiety
ANS: 4
Dissociative identity disturbance is exacerbated when the client's anxiety escalates. Identifica-tion of increasing anxiety permits the client to exercise anxiety-management strategies and pre-vent dissociation. 1. The client should be expressing such feelings to others. 2. The client should refer to himself in the first person. 3. Use of assertive behavior is desirable.
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An older patient reports a significant amount of cheese, milk, and calcium-fortified orange juice in her diet. She also takes a 750 mg calcium supplement at breakfast. What should the nurse instruct the patient about her calcium intake?
A) Keep the intake of calcium to 30% of kilocalories or less B) Take calcium supplement doses totaling not more than 5,000 mg C) Limit the intake of calcium to a total of 2,000 mg or less from all sources D) Follow the RDA listed on the milk products' nutrition labels for calcium intake
Which of the following positions is the lowest angle at which neck vein distention would be considered significant?
1. client in supine position 2. head of the bed elevated 10 to 20 degrees 3. head of the bed elevated 30 to 45 degrees 4. head of the bed at 90 degrees
Leaving an unconscious patient exposed during a treatment or procedure is a violation of the ethical principle of
a. fidelity. b. autonomy. c. justice. d. veracity.
A woman who is 2 months pregnant tells the nurse that she has never received the MMR vaccine and has not had these diseases. She has a 3-year-old and a 5-year-old child who have not been immunized
The nurse will counsel the patient to perform which action? a. Delay obtaining the vaccines for her children and herself until after her baby is born. b. Have her children vaccinated now and obtain the vaccine for herself after the baby is born. c. Obtain the MMR vaccine for her children and herself when she is in her third trimester of pregnancy. d. Obtain the MMR vaccine for her children and herself within the next few weeks.