The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome
Which of the following assessment findings would increase the patient's risk of developing this syndrome? 1. body mass index of 23%
2. history of alcoholism
3. no chronic health problems
4. employed as a laborer and stopped smoking 15 years prior
2
Rationale: Patient-related risk factors for developing systemic inflammatory response syndrome include age greater than 65, baseline organ dysfunction, alcohol abuse, malnutrition, and immunosuppression. The one assessment finding that would increase the patient's risk of developing systemic inflammatory response syndrome would be a history of alcoholism. The other findings would not contribute to the development of the syndrome and are incorrect choices.
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During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This behavior is an example of:
a. Social phobia b. Compulsive disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder
The nurse distrusts the male caregiver, the son of an older woman, and collaborates with social services about potential resources for abused older adults
Which characteristics of the caregiver does the nurse report to social services as indicators of potential elder abuse? (Select all that ap-ply.) a. Collects unemployment benefits. b. Finds fault with any nursing care. c. Takes frequent breaks for smoking. d. Lives in the same house as his mother. e. Makes demands on assistive personnel. f. Sits at his mother's bedside for hours dai-ly.
A male patient has been admitted with a fever and malaise. The health care provider has ordered a clean catch midstream specimen for urinalysis on this patient
To collect the urine specimen, the nurse should instruct the patient to do which of the following? a. Return to bed to obtain the specimen using a straight catheter insertion. b. Use sterile gloves to cleanse his penis and collect the specimen in a sterile cup. c. Ask the patient to void into a cup or urine collection container. d. Cleanse his penis, begin his stream, and then void into a sterile cup.
A client tells the nurse that she often feels pressure from her family to spend every Sunday with them. However, her husband does not want to participate and stays at home waiting for her to return
The nurse realizes this client's self-concept is being determined by: 1. Stressors. 2. Resources. 3. History of successes and failures. 4. Family and culture.