List the factors that affect the grief reaction to a burn injury that a client faces on discharge from the hospital. Select all that apply
1. Body image change
2. Loss of physical functioning
3. Potential change in vocation
4. Separation from home and family
5. Change in family role patterns
1. Body image change
2. Loss of physical functioning
3. Potential change in vocation
4. Separation from home and family
5. Change in family role patterns
Rationale: Body image change. The change in body image is the primary reason for the grief response. Loss of physical functioning. Loss of psychical functioning impacts many aspects of the grief reaction, such as change in vocation and change in family role patters. Potential change in vocation. This is included in the grief response because it poses a threat to financial independence. Separation from home and family. Recovering from a major burn injury necessitates a prolonged hospitalization. This means separation form loved ones, which causes grief. Change in family role patterns. A shift in family role patterns, especially the bread-winner role, upsets family structure and is a factor in the grief process.
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A client became aggressive, struck another client, and required seclusion. The best documentation is
a. "Client apparently doesn't like client X, as evidenced by his striking client X when client attempted to leave day room to go to bathroom. Seclusion necessary at 2:15 PM. Plan: Maintain seclusion for 8 hours and keep this client and client X away from each other for 24 hours.". b. "Seclusion ordered by Dr. at 2:15 PM when voices told the client to hit another client.". c. "Client pacing, shouting at people not present in the environment. Chlorpromazine 50 mg administered po at 1 PM with no effect by 2 PM. At 2:15 PM client shouted that he would punch the first person who got near him, then struck client X on the jaw with his fist as client X walked out of day room to go to bathroom. Client physically restrained by staff and placed in seclusion by order of Dr. Y.". d. "Seclusion ordered by Dr. Y for aggressive behavior, begun at 2:15 PM. Maintained for 2 hours without incident. Outcome: Client calmer.".
Preoperative nursing responsibilities for a child having surgery include which of the following? (Select all that apply.)
a. Prepare for separation from caregivers. b. Complete presurgery assessment. c. Provide beverage or bottle 1 hour prior. d. Obtain vital signs. e. Assess operative site. f. Observe for shock. g. Check dressing for bleeding or drainage.
The nurse is instructing a healthy 60-kilogram client on nutritional and hydration needs. The nurse explains that the client will need how many 8-ounce glasses of water per day to help meet the body's daily fluid requirements?
1. 8?11 glasses 2. 15?20 glasses 3. 5?6 glasses 4. 2?3 glasses
Which symptom would be highest priority for the nurse to monitor while the client is being treated with peripheral vasodilators?
a. Bradycardia b. Dizziness c. Headache d. Pallor