A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom?
A. "I can't stop my sexual urges. They have led me to numerous affairs."
B. "I'm the world's most perceptive attorney."
C. "My wife is distraught about my overspending."
D. "The FBI is out to get me."
B
Grandiosity is defined as a belief that personal abilities are better than anyone else's. This client is experiencing delusions of grandeur, which are commonly experienced in mania.
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Rob, a 15-year-old, has lost 30 pounds in 3 months. Rob is 6 feet tall and weighs 110 pounds. He is aspiring to be a model and he tells you that he is fat: "Just look at how puffy my feet and arms still are. I have to get rid of the fat there."
The nursing diagnosis based on this information is: A. Body image disturbance: distorted perception. B. Knowledge deficit: nutritional requirements. C. Altered nutrition, more than body requirements. D. Potential for suicide.
The nurse is auscultating a patient's chest for breath sounds and is unsure if the sounds are crackles or simply the friction of the stethoscope's diaphragm against the patient's chest hairs. What should the nurse do?
A) Move the location of the diaphragm slightly and listen for a few more breaths. B) Prioritize the assessment findings from percussion and inspection. C) Move the diaphragm slowly across the surface of the patient's skin while auscultating. D) Auscultate the patient's lateral thorax rather than his anterior thorax.
An intramuscular dose of antipsychotic medication needs to be given to a client who is becoming
increasingly more aggressive. The client is in the day room. The nurse should a. enter the day room and say "Would you like to come to your room and take some medication that your doctor has ordered for you?" b. take three staff members to the day room as a show of solidarity and say "Please come to your room so I can give you some medication that will help you feel more comfortable.". c. take a male nursing assistant to the day room and tell the client "You can come to your room willingly so I can give you this medication, or the aide and I will have to take you there.". d. enter the day room, place the client in a basket hold, and say "I am going to take you to your room to give you an injection of medication to calm you.".
The patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this patient?
Select all that apply. 1. romaine lettuce 2. seafood 3. white rice 4. lean red meat 5. almonds