While providing personal care for a client, the nurse observes that the client is not comfortable with the close physical proximity. How will the nurse alleviate the discomfort of the client during personal care?
A) Speak words or phrases in the client's language.
B) Maintain sufficient distance.
C) Ensure that the client's family member is present.
D) Provide simple explanations of the need for physical proximity.
D
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A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?
a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.
Place the nursing intervention in appropriate order for the immediate care of a patient with a penetrating wound of the eye. (Separate letters by a comma and space as follows: A, B, C, D)
a. Assess eye, do not remove object b. Cover both eyes with an eye shield or cup c. Lay the patient down flat d. Check for the irregularity of the pupil e. Obtain medical attention immediately
The client consumes 240 mL of milk, two waffles, and 128 mL of orange juice. Which of the data about the client's food consumption does the nurse use on the graphic record?
1. Intake = 368 mL 2. Ate the entire breakfast 3. Intake = 368 mL plus two waffles 4. 8 oz milk, 4 oz orange juice
A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client?
A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.