Which of the following are examples of maladaptive measures?
a. excessive eating c. future-oriented planning
b. goal development d. daydreaming
A
Defense mechanisms such as somatization or abuse of drugs or alcohol are considered to be maladaptive when they become the only way a person responds to a threat, thus preventing the person from progressing toward resolution and acceptance of stress. An acute state of disorganization or crisis occurs when a person's stressors exceed her or his coping ability.
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After emptying the urine from a urinal, which actions by the nurse are appropriate?
Select all that apply. 1. Rinsing the urinal 2. Recording the output on the intake and output record, if indicated 3. Returning the urinal to the bedside area, where the client can reach it, if the male client prefers 4. Placing the urinal between the client's legs and propping the penis in the opening, if the client is unable to do this independently 5. Donning clean gloves
The nurse is ordered to apply restraints to a toddler who keeps pulling at the tubes in his arm. Which of the following criteria must occur to ensure proper use of these restraints? Select all answers that apply
A) The nurse must check the restraints every 15 minutes while they are in place. B) Secure the restraints with ties to the side rails, not the bed or crib frame. C) Assess the temperature of the affected extremities, pulses, and capillary refill every 15 minutes after placement. D) Use a clove-hitch type of knot to secure the restraints with ties. E) Remove the restraint every 2 hours to allow for range of motion and repositioning. F) Encourage parent participation, providing continuous explanations about the reasons and time frame for restraints.
The client following major surgery under general anesthesia arrives on the nursing unit 4 hours following surgery. The first set of vital signs are T 37.6; P 100; R 30; and BP 100/68. The nurse's first action should be to:
a. Notify the health care provider. b. Assess the vital sign readings from the recovery room. c. position the client for comfort and assess pain level. d. prepare to increase the client's IV rate and administer blood products.
Which of the following is a laboratory finding that is commonly found in patients with anorexia nervosa?
a. Hypercholesterolemia b. Hypermagnesmia c. Leukocytosis d. Decreased thyrotropin (TSH)