A female client disclosed to the nurse that she is in an abusive situation. This information will be used to contribute to:
1. Axis IV.
2. Axis III.
3. Nothing, since this is confidential information and should not be shared.
4. Axis I.
1
Rationale: Axis IV is used to identify psychosocial problems that may affect the diagnosis and treatment of mental disorders. Clinicians use Axis III too.
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A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)
a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.v
A patient is diagnosed with acute interstitial pancreatitis. The nurse would reinforce which information about this patient's prognosis?
1. This disorder often progresses to multiple organ dysfunction with a poor outcome. 2. This disorder often causes pancreatic edema, which will resolve with good results. 3. Extensive fat and tissue necrosis occurs with this type of pancreatitis. 4. The patient will most likely have irreversible damage to the pancreas.
The nurse is observing a UAP performing a bed bath for a client. Which action by the UAP requires the nurse to intervene?
A. Washing the client's arms from wrists to shoulders. B. Washing the client's eyes and face first before the rest of the body. C. Washing, rinsing, and drying the client's leg from thigh to ankle. D. Washing the client's back and then the perineum.
A young male student becomes very hungry during class. He begins thinking of a cheeseburger and fries, his favorite meal. These thoughts will trigger which phase of gastric secretion?
a. Cephalic b. Gastric c. Enteral d. Intestinal