The nurse knows that when designing a plan of care for a client with serious mental illness, the recovery and rehabilitation goals must be: Standard Text: Select all that apply
1. Attainable
2. Realistic
3. Permanent
4. Immediate
5. Flexible
1,2,5
Rationale: Client goals must be realistic and attainable, keeping in mind the need to be flexible depending on crises and depleted resources (emotional and financial). The goals that will bring change are not immediate, instantaneous, or initially permanent.
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The nurse working on the postpartum unit is caring for a woman who is three days postpartum
The client says, "If I would have known my breasts were going to get this full and painful if I breastfed, I would have made a different decision about how to feed the baby." The nurse's best response is: 1. "Oh well, it's too late to change your mind now." 2. "This happens to all new mothers, whether they breastfeed or not." 3. ""It's not too late to change your mind and bottle-feed the baby." 4. "You are experiencing engorgement, and there's nothing you can do until it subsides."
A pregnant woman is admitted to a CCU after a motor vehicle crash. She is endotracheally intubated and mechanically ventilated
Respiratory assessment reveals diminished lung sounds at posterior bases, decreased functional residual capacity, and increased spontaneous tidal volume. What is the highest-priority nursing action? A) Obtain orders for ventilator setting adjustments to compensate for the abnormal findings. B) Suction the patient via the endotracheal tube to stimulate cough. C) Continue the present plan of care, as the findings are expected. D) Obtain orders for an inhaled bronchodilator for bronchospasm.
The nurse is taking a health history on a new patient hospitalized with parasthesias. What is an appropriate question for the nurse to ask the patient to elicit information on altered sensations?
A) How does the strength in the affected extremity compare to the strength in the unaffected extremity? B) Does the color in the affected extremity match the color in the unaffected extremity? C) How does the feeling in the affected extremity compare with the feeling in the unaffected extremity? D) How does the affected extremity look compared to the unaffected extremity?
Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus?
a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.