A disheveled, severely depressed client with psychomotor retardation has not showered for several
days. The nurse should
a. avoid forcing the issue.
b. firmly and neutrally assist the client to shower.
c. calmly tell the client that he or she must shower or be secluded.
d. bring the issue up at the community meeting.
B
When clients are unable to perform self-care activities, staff must assist them rather than ignore the
issue (option A). Being better groomed increases self-esteem. Options C and D are punitive.
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A 5-year-old African American patient has been admitted to the pediatric intensive care unit with pheochromocytoma. The physician has ordered phentolamine. The nurse knows that the other indication for phentolamine is what?
A) Migraine headaches B) Extravasation of IV norepinephrine or dopamine C) Life-threatening arrhythmias D) Heart failure
A nurse is caring for a neonate who is 22 inches in height. The nurse explains to the neonate's mother that by 1 year, the infant's expected height will be:
a. 29 inches. b. 33 inches. c. 44 inches. d. 56 inches.
The nurse is developing a care plan for a patient who is taking an anticholinergic drug. Which nursing diagnosis would be appropriate for this patient?
a. Diarrhea b. Urinary retention c. Risk for infection d. Disturbed sleep pattern
A client having her fourth child is admitted to the labor unit and is accompanied by a doula. The intrapartum nurse expects the doula to assist with:
A. Fetal monitoring and relaxation techniques. B. Physical and emotional comfort techniques. C. Breathing techniques and labor assessment. D. Massage and vaginal exams.