The Nursing Care Plan of a newly admitted 82-year-old resident to a long-term care facility who has had congestive heart failure and osteoarthritis calls for the documentation of re-gressive behavior
Of these behaviors observed by the nurse, the ones documented as re-gression are (select all that apply): 1. talking nonstop to staff and other residents.
2. wets and soils self several times a day.
3. wakes in the middle of the night and can't return to sleep.
4. wears the same clothes day after day.
5. cries frequently for no apparent reason.
2, 4, 5
Behaviors that are infantile or immature in the absence of dementia are considered regres-sive. Frequent episodes of crying and inattention to personal hygiene are regressive in nature. Excessive talking and wakefulness may be related to relocation anxiety, but are not re-gressive.
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A woman who is 8 months pregnant is being assessed on a routine clinic visit. Which assessment findings require further assessment and treatment?
A) Blood pressure increased by 10 points from previous visit B) Blood pressure 150/95 mm Hg C) 1+ edema of lower extremities D) Urine output 750 mL in 24 hours
Care planning for a patient undergoing detoxification for both alcohol and sedative-hypnotics is based on the treatment principle that states that:
a. medications are used to treat symptoms as they appear. b. a cross-tolerant drug is used to gradually wean the patient. c. liver function is preserved best by avoiding detoxification drugs. d. forcing fluids is therapeutic since detoxification mainly occurs in the kidneys.
When collecting data on a 7-year-old child during a well-child
visit, the nurse finds that the child has gained 5 lb and grown 5 in in the last year. Using knowledge of normal growth patterns of the school-age child, what does the nurse recognize that these findings indicate? A) The child's weight and height are within expected patterns of growth. B) The child's weight falls within an expected range and the increase in height is less than what would be expected. C) The child's weight is above an expected range and the height is within an expected range. D) The child's weight is below an expected range and the height is above an expected range.
A patient who has fibromyalgia is diagnosed with major depression. The provider orders a TCA. The nurse will teach this patient to:
a. avoid foods containing tyrosine. b. consume alcohol in moderation. c. sit or lie down when feeling lightheaded. d. take the medication in the morning.