The environment of a patient with dementia includes photographs of her family, soft music, and low lighting. She wears her own jewelry—necklaces and rings she had received as gifts. Unused electrical outlets are covered
Once a day, she exercises with a group. What might a nurse suggest is missing from this picture? A) Nutritional supplements
B) A walker
C) An ID bracelet
D) A commode chair
C
Feedback:
The patient should be wearing an ID bracelet in addition to her necklaces and rings. The patient is ambulatory (she exercises) and so does not require a walker or a commode chair. Supplements may not be needed by this patient.
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A 30-year-old woman who has given birth 12 hours prior is displaying signs and symptoms of disseminated intravascular coagulation (DIC)
The client's husband is confused as to why a disease of coagulation can result in bleeding. Which of the nurse's following statements best characterizes DIC? A) "So much clotting takes place that there are no available clotting components left, and bleeding ensues." B) "Massive clotting causes irritation, friction, and bleeding in the small blood vessels." C) "Excessive activation of clotting causes an overload of vital organs, resulting in bleeding." D) "The same hormones and bacteria that cause clotting also cause bleeding."
A patient is receiving IV amphotericin B (Fungizone) for a systemic fungal infection. Which assessment parameter should you perform to determine whether the patient is having an adverse reaction to the therapy?
a. Measure abdominal girth for presence of ascites b. Assess mouth and oral cavity for candidiasis c. Assess infusion site for phlebitis d. Assess calves for pain
The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse takes which priority action?
1. Obtains a court order for the surgery 2. Sends the client to surgery without the consent form being signed 3. Has the hospital chaplain sign the informed consent immediately 4. Obtains a telephone consent from the family member witnessed by two persons
A client with anorexia nervosa has refused meal trays and supplemental feedings for 3 days fol-lowing admission to the general hospital. The nurse can anticipate that intervention will include:
1. IV infusions beginning immediately and continuing for 48 hours after client be-gins eating 2. Tube feedings until the client eats 90% of all meals for 1 day 3. Placing the client on suicide precautions and one-to-one observation 4. Limiting peer group visitors for 2 weeks