A client is experiencing anxiety related to hospitalization. When assessing this client, the nurse anticipates which assessment finding?
a. Increased socialization
b. Improved sleep
c. Greater recall ability
d. Disengagement from the stressor
ANS: D
Stress doesn't always look like a "stressor response." Some people internalize stress. They withdraw or seem disengaged from an obvious stressor, when stressed.
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The nurse is completing the psychosocial history on a newly admitted adult client. The client reports trouble concentrating, rapid heartbeats, irritability, and inability to make decisions. Based on these assessment findings, which does the nurse suspect?
1. A stress reaction. 2. Role confusion. 3. An impending heart attack. 4. Dysfunctional anxiety.
A client agrees to receive long-term hemodialysis to treat acute renal failure. For which surgical procedure should the nurse instruct this client?
A) Insertion of a double-lumen catheter into the subclavian artery B) Placement of a peritoneal catheter C) Insertion of a subarachnoid-peritoneal shunt D) Placement of an arteriovenous fistula
When collecting data on a child with hydrocephalus, in addition
to the child likely having a large head at birth and rapid head growth, which sign should the nurse recognize as a manifestation of this disorder? A) Posterior fontanelle bulging and tense B) Eyes appear to be pushed downward C) Hands short with curved fingers D) Neck area is thickened and strong
Which patient is most prone to metabolic alkalosis? A patient with:
a. retention of metabolic acids. b. hypoaldosteronism. c. excessive loss of chloride (Cl). d. hyperventilation.