Which statement made by a patient should serve as the priority focus for the plan of care?
a. "I can always trust my family."
b. "It seems like I always have bad luck."
c. "You never know who will turn against you."
d. "I've been hearing the voices of my dead parents."
D
The correct response indicates that the patient may be experiencing auditory hallucinations. The other statements are significant but require additional exploration.
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A young man asks the nurse about the goal of the cancer therapy his mother is receiving. What is the nurse's best response?
A) "The goal is to limit the cancer cells so the immune system can respond without causing too much toxicity to your mother." B) "The goal is to kill the cancer cells as quickly as possible before they can spread so your mother will be well again." C) "The goal is to control the speed at which new cancer cells grow so the medication has a better chance to work." D) "The goal is to keep the cancer cells from spreading all over your mother's body and choose the drug with the fewest adverse effects."
When you assess the client with a new tracheotomy at the beginning of your shift, you observe that the tracheostomy tube is pulsating in synchrony with the client's heartbeat. What is your best action?
A. Notify the physician immediately. B. Stabilize the tube by reapplying the ties. C. Document the observation as the only action. D. Increase the inflation pressure of the tracheostomy cuff.
A nurse explains to a preceptor student that values clarification helps with intrapersonal communication because
a. communication is enhanced when it occurs between people with similar values. b. it allows the nurse to separate his or her values from those of the patient. c. it helps the nurse avoid saying things that might offend or anger others. d. understanding values will help prevent communication misunderstandings.
A client has been prescribed quetiapine (Seroquel) for delusional disorder. In teaching the client about this medication, the nurse must be certain to include which of the following information?
A) Quetiapine can cause breast milk production. B) One of the common side effects is dry mouth. C) If dizziness is experienced, the client must call the doctor immediately. D) Quetiapine can cause you to crave sugar.