A patient in the emergency department says, "I took a drug that makes me feel like I'm outside my body looking at the world. Colors move like music." The nurse should assess that the patient
a. probably has schizophreniform disorder.
b. has probably ingested a hallucinogen.
c. is experiencing formication.
d. is using confabulation.
B
Symptoms of hallucinogen use include depersonalization, loss of reality, hallucinations, synesthesia, panic, paranoid thinking, and loss of contact with reality. Data given in the scenario do not support a schizophreniform disorder, formication (abnormal crawling sensations under the skin), or confabulation.
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A nursing student visits a nursing instructor's office and the instructor states, "Gina, are you tanning in a tanning booth?" The nursing student says yes. The nursing instructor's best response would be to instruct her on:
A) the rate of cancer from exposure to sun and tanning beds. B) the need to apply sunscreen after tanning sessions. C) the application of skin lotions to protect from skin ulcers. D) the need to consume milk products to enhance bone development.
Which outcome should the nurse use for evaluation of the efficacy of interventions designed for this nursing diagnosis?
a. the client's family inspects the skin for reddened areas daily b. the client exhibits no reddened areas or breaks in the skin c. the nursing staff rotates the client's kinetic bed per unit protocol d. the physical therapist performs passive ROM exercises
A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically
On the basis of this information, this woman should feed her infant about every 2.5 to 3 hours when she: a. Waves her arms in the air. c. Has hiccups. b. Makes sucking motions. d. Stretches her legs out straight.
Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant?
a. Delayed growth and development c. Ineffective infant feeding pattern b. Ineffective thermoregulation d. Risk for infection