A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action
a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security."
b. Tell the client, "You are in a safe place where you will be helped."
c. Administer a prn dose of an antipsychotic medication.
d. Tell the client, "You don't need to worry about that."
ANS: B
The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.
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A patient tells the nurse that she does not like to "go to the doctor" and is feeling anxious about "being in this place." When the nurse checks her blood pressure, it is elevated along with her heart rate
The nurse rechecks her blood pressure about 10 minutes later and it is normal. The patient asks the nurse if she should be concerned that she may have hypertension. What statement should guide the nurse's response? A) She should not worry; it was stress related and her regular blood pressure is good. B) The first blood pressure was part of a simple stress response; our long-term blood pressure is controlled by negative feedback systems. C) Blood pressure is only one measure of hypertension; she should review this with the doctor and plan to recheck it on a regular basis. D) The respiratory infection is the probably the cause of the elevated blood pressure, and, with treatment, her blood pressure should remain normal.
The nurse is conducting a seminar regarding cultural implications for physical assessment. A client of which ethnicity might prohibit the nurse from examining the head?
1. Caucasian from the United States. 2. African American. 3. Mexican American. 4. Cambodian American.
The client is receiving treatment for his depression twice a week at his HMO. This client is receiving health care through a
1. county care system. 2. private care system. 3. managed care system. 4. physicians' care system.
A nurse asks a client how she has been sleeping. Which of the following best describes the rationale behind this question? (Select all that apply.)
a. Accidents and injury may occur with the sleep-deprived client at fault. b. Interventions for sleep problems are primarily common sense. c. Many adults report sleep problems or occasional lack of sleep. d. Many important functions occur during sleep. e. Nurses can determine whether the patient has a sleep disorder. f. A sleep assessment is easy and inexpensive to complete.