Which phase of reality shock is a nurse demonstrating who works in a busy intensive care unit that
is constantly understaffed and after 18 months decides to quit the job and obtain a position as an
office nurse for a local physician?
A) Honeymoon B) Rejection C) Resolution D) Recovery
B
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While performing a focused assessment on the client, the nurse notes a skin rash, which the nurse correctly documents as:
1. Rash on face, arms, and trunk. 2. Maculopapular rash over trunk that client says itches. 3. 2cm boil noted on the client's shoulder. 4. Erythematous butterfly-shaped rash noted over the client's cheeks and nose.
The nurse is working on a rehabilitation unit and caring for a client whose family members come in every day and ask, "What progress was made today?" The nurse best responds to these repeated questions by:
1. Informing the family they don't need to ask this question because they will be told when progress is made. 2. Informing the family that the client's progress can be assessed best by them when they visit. 3. Providing the client's progress and daily activities, with the client's permission. 4. Informing the family that they will need to talk with the client to get that information.
Following a nephrectomy, which assessment finding is most important in determining nursing care for the client?
A) Urine output of 35 to 40 mL/hour B) Pain of 3 out of 10, 1 hour after analgesic administration C) SpO2 at 90% with fine crackles in the lung bases D) Blood tinged drainage in Jackson-Pratt drainage tube
An elderly patient has had a CVA in the anterior cerebral circulatory system (frontal lobe). What symptoms are most likely expressed?
A. Neglect of body and difficulty organizing space B. Wernicke's aphasia (difficulty understanding speech) C. Disorders of behavior and cognition D. Bilateral motor and sensory problem