A client with severe mental illness who lived independently in an apartment and attended a
psychosocial rehabilitation program 5 days a week appears at the emergency department seeking
admission to the inpatient unit.
The mental status examination reveals no acute symptoms of
psychiatric disorder. Her chief complaint is that she has no money to pay her rent or refill her
antipsychotic medication prescription. The best action for the emergency department nurse would be
to
a. arrange for a short in-patient admission and begin discharge planning.
b. send the client to a homeless shelter until housing can be arranged.
c. involve the client's case manager to provide crisis intervention.
d. explain that one must have psychiatric symptoms to be admitted.
C
The client is experiencing a crisis. Crisis stabilization, undertaken by the case manager who knows
the client, can undoubtedly avert an unnecessary hospitalization. Options A and B carelessly uses
scarce resources. Option D may prompt the client to feign symptoms.
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A patient, age 53, is receiving chemotherapy for Hodgkin's disease, stage IV. As a side effect of chemotherapy, he is experiencing stomatitis. Which nursing diagnosis would be identified for planning the nursing interventions for this patient?
a. Fatigue, related to stomatitis b. Imbalanced nutrition: less than body requirements c. Risk for disuse syndrome d. Risk for ineffective breathing pattern
It has been calculated that a patient in the intensive care unit needs 1800 calories each day to sustain normal metabolic functioning. The nurse calculates that which number of calories is needed to sustain central nervous system (CNS) functioning?
1. 1440 calories 2. 360 calories 3. 900 calories 4. 720 calories
Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?
a. Cover stoma with sterile gauze and ventilate through stoma. b. Attempt to reinsert the tracheostomy tube with the obturator in place. c. Assess the patient's oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.
Weak and distended veins cause varicosities
Indicate whether the statement is true or false