During a home care visit, the client becomes agitated, hostile and threatening; the nurse is not able to deescalate the client. What immediate action should the nurse take?
A) Alert the nurse supervisor. B) Call the physician.
C) Call 911 for emergency assistance. D) Leave the client in the care of the family.
C
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A client is diagnosed with systemic lupus erythematosus (SLE). Which of the following would be most appropriate for the nurse to use to evaluate the client' s stage of disease?
A) Observe the client's gait. B) Review the client's medical record. C) Inspect the client's mouth. D) Auscultate the client's lung sounds.
A nursing action that would ensure a medication is given to the right patient would be to
1. check the patient's identification bracelet. 2. verify the medication record with the chart. 3. verify the room number with the chart. 4. ask the patient to state his or her birth date and Social Security number.
A patient tells the nurse that he dreads the winter, stating he does not spend much time outdoors because of the bad weather and he becomes blue and depressed. Then all of his muscles hurt and he "just is not able to do anything."
The nurse realizes this patient's symptoms are worse in the winter due to: 1. A decrease in serotonin. 2. Spending too much time in dry heat. 3. A lack of motivation. 4. Poor diet.
The nurse is assessing newborns in the nursery. Which assessment finding places a newborn at risk for developing physiologic jaundice?
1. Molding 2. Mongolian spots 3. Cephalohematoma 4. Telangiectatic nevi