When providing care for a client who has been restrained, which of the following is the nurse's priority?
A) Helping the client understand the rationale for the restraints
B) Ensuring that the client learns about the consequences of violence
C) Reassuring other clients on the unit that they are safe
D) Ensuring the client's safety while restrained
Ans: D
When a client requires restraints or seclusion, the priority aspect of nursing care is ensuring that the client does not experience injury while restrained. This requires frequent, vigilant assessment.
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A patient with emphysema enters the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26 . After positioning the patient in high Fowler's, the nurse should:
a. attempt to help the patient slow her respi-rations. b. coach in pursed-lip breathing. c. give oxygen at 5 L/min by nasal cannula. d. reposition patient in orthopneic position.
When working with a patient suspected of substance abuse, the nurse is particularly interested in determining the cause of a patient's
a. acute abdominal pain. b. recurring insomnia. c. extensive history of falls. d. chlordiazepoxide (Librium) prescription.
What step in the nursing process is most closely associated with cognitively skilled nurses?
A) Assessing B) Planning C) Implementing D) Evaluating
An elderly woman who is incontinent of stool following a cerebrovascular accident will have the following nursing diagnosis
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