A client diagnosed 3 months ago with HIV infection tells the nurse, "I feel so sad every time I think of my diagnosis
I cry a lot, and I don't go out as much as I did before. It just doesn't seem right to laugh. I don't have a good appetite, but I force myself to eat something at every meal, so I haven't lost weight." From this description, the nurse would determine that the client's symptoms most closely correspond to those of:
1. Bipolar disorder
2. Major depression
3. Adjustment disorder
4. Dysfunctional grieving
ANS: 3
The client's symptoms most closely resemble those of adjustment disorder with depressive fea-tures. The symptoms are of low mood but are not as severe as symptoms seen with major depres-sion. The symptoms do not resemble bipolar disorder and are not entirely consistent with dys-functional grieving.
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To estimate the length of the nasogastric (NG) tube that should be inserted to reach the client's stomach, the nurse should use the NG tube to measure the distance from the:
a. client's earlobe to the sternum after placing the client in a sitting position b. base of the client's nose to the umbilicus after placing the client in a supine position c. mouth to the earlobe and then to the xiphoid process after placing the client in a supine position d. tip of the client's nose to the earlobe and then to the xiphoid process after placing the client in a sitting position
A client admitted for a heroin overdose received naloxone (Narcan), which relieved his altered breathing pattern. Two hours later he complains of muscle aches and abdominal cramps. He also displays a runny nose and is shivering
What assessment can be made? A) The client is experiencing symptoms of narcotic withdrawal. B) The client is experiencing relapse. C) The client is experiencing a side effect to the naloxone. D) The client should be placed on seizure precautions.
The student nurse is preparing to administer an IV bolus medication through a small-gauge IV catheter. The student notes that there is no blood return on aspiration. Which action by the student should the nursing instructor question?
a. Checking the IV site for redness and swelling b. Immediately stopping the IV infusion and removing the IV catheter c. Checking to see if the IV is infusing without difficulty d. Injecting the IV medication if no signs of infiltration
A nurse in a medical care center notices that the sphygmomanometer used to measure the blood pressure of clients has a defective part and gives inaccurate readings. What initial action should the nurse take in this case?
A) Report and label the defective sphygmomanometer immediately. B) Replace the sphygmomanometer immediately. C) Try to repair the defect in the instrument. D) Order a new sphygmomanometer.