The client on the mental health unit who should be assessed as being at highest risk for directing
violent behavior toward others is
a. E, who has obsessive-compulsive disorder and performs many rituals.
b. F, who has paranoid delusions that she is being followed by members of the
mafia.
c. G, who has severe depression with delusions of worthlessness.
d. H, who has completed alcohol withdrawal and is beginning a rehabilitation
program.
B
F has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may
strike out against those believed to be persecutors. The other clients have better reality-testing
ability.
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When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
a. Between the scapulae b. Third intercostal space, MCL c. Fifth intercostal space, midaxillary line (MAL) d. Over the lower lobes, posterior side
A nurse is speaking to a group of high school girls about not smoking. The nurse would caution them that the risk of CHD in women who smoke is greater than that for nonsmoking women by
a. two times. b. three times. c. four times. d. five times.
The home health nurse is making the first visit to a client who will continue to need sterile dressing changes after abdominal surgery. In assessing the home environment, which must be considered when performing the home dressing change?
A. There is dust on many of the surfaces. B. The furniture appears worn. C. There is a cat that is allowed on the furniture. D. There are dirty dishes on the dining room table.
Which factor contributes to the production of mucus associated with chronic bronchitis?
a. Airway injury b. Pulmonary infection c. Increased Goblet cell size d. Bronchospasms