The priority nursing intervention for clients diagnosed with delirium includes which of the following?
A) Reduce environmental noise.
B) Initiate safety precautions.
C) Reorient the client to date, time, and place.
D) Explain all procedures and what is happening to the client.
B
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Where should a nurse performing a backrub begin?
a. Shoulder b. Base of the neck c. Sacral area d. Lumbar area
When describing tardive dyskinesia (TD) associated with the use of antipsychotic medication, which of the following would the nurse integrate into the teaching plan? Select all that apply
A) TD is an early-appearing adverse reaction. B) TD involves rhythmic, involuntary movements of the facial structures. C) TD is a reversible adverse effect of antipsychotic drugs. D) TD is less likely to occur with the use of atypical psychotics. E) TD can occur after discontinuation of antipsychotic drug therapy.
You are the admitting nurse in a short-stay surgical unit. What do you need to verify before the patient is taken to the preoperative holding area?
A) Preoperative teaching content B) That the family is aware of the length of the surgery C) That follow-up home care is not necessary D) That the family understands the patient will be discharged right after surgery.
To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the
A) Front of the ear B) Mastoid process C) Top of the head D) Affected ear