A patient with a history of self-mutilation says to the nurse, "I want to stop hurting myself." What is the initial step of the problem-solving process to be taken toward resolution of a patient's identified problem?
a. Deciding on a plan of action
b. Determining necessary changes
c. Considering alternative behaviors
d. Describing the problem or situation
D
The nurse learns how well the patient understands the problem by asking for a detailed, in-depth description of situations, thoughts, feelings, and behaviors relevant to the identified problem. This step must be completed before moving through the problem-solving process. The other actions are premature.
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Hypoglycemia is manifested by:
1. Blood glucose level less than 60 mg/dL. 2. Polydipsia. 3. Blood glucose level of 60-75 mg/dL 4. Polyuria.
A nurse is presenting a health education program to a group of older adults at a senior citizens center. Considering the physiological changes of this age group, how should the nurse set the temperature of the room?
1. It should be set at a temperature that is comfortable for the nurse. 2. It should be set cooler than what is comfortable for the nurse. 3. It should be set warmer than the nurse's preference. 4. The temperature of the room is not one of the nurse's concerns.
When taking a radial pulse, you need to use:
a. Your thumb b. Your 2 or 3 fingertips c. Your ring and little fingertips d. A stethoscope.
A nurse performs a sterile urine specimen collection from an ileal conduit. Which action by the nurse is incorrect and may lead to inaccurate results?
A. Removing the collection pouch prior to obtaining the sample. B. Inserting the tip of the catheter into the stoma approximately 4 cm (1.5 inches). C. Obtaining the sample from the collection pouch. D. Placing towels around the stoma.