For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take?
a) Closely assess for nonverbal signs such as grimacing or rocking.
b) Obtain baseline behavioral indicators from family members.
c) Look at the MAR and chart to note the time of the last dose of analgesic and the client's response.
d) Give the maximum PRN dose within the minimum time frame for relief.
Answer: b) Obtain baseline behavioral indicators from family members.
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The nursing models that focus on achievement or restoration of stability instead of the growth model for change include
A) Callista Roy's Adaptation Model. B) Dorothea Orem's Self-Care Deficit Theory. C) Jean Watson's Human Science and Human Care Theory. D) Martha Rogers' Science of Unitary Human Beings Theory.
The patient has a blood pressure reading of 126/84 mmHg. She asks the nurse if she has high blood pressure. What is the best response by the nurse?
1. "You have prehypertension, but it isn't really serious." 2. "You have prehypertension; let's discuss your lifestyle." 3. "You have prehypertension; unfortunately, this will progress to hypertension." 4. "You have prehypertension, and must begin medication."
The nurse is caring for a client who is exhibiting severe respiratory distress and is receiving supplemental oxygen through a nonrebreather mask. While assessing the client, the nurse notes that the bag attached to the mask is deflated. Which is the nurse's best action?
A. Document it as functioning normally. B. Decrease the flow of oxygen to the mask. C. Increase the flow of oxygen to the mask. D. Prepare for endotracheal intubation.